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Respond to the 2 (respond Threat) 300 words each using APA 7 edition
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Discussion Thread: Group Leadership
A litany of responsibilities come with being a group leader. Group leaders are accountable for the group norms, development, activities, and the interventions each group needs (Brown, 2018). But it is also important to review the characteristics of a leader and how those characteristics impact the leader’s self-development and align with a psychoeducational group. The characteristics of a group leader are traits and qualities that define who the leader is. Honing in on self-development as a psychoeducational leader provides an introspective view to grow and to learn, which will better support the group (Newstead et. al, 2024). Three pivotal points as to why self-development is key for psychoeducational groups are: 1) Self-development provides an opportunity to grow professionally and personally, 2) It helps develop a deeper self-awareness, and 3) Self-development builds confidence in the group leader. Working on areas of growth through self-development provides the leader core characteristics that enhance their leadership skills (Brown, 2018).
Self-development provides group leaders an opportunity to grow professionally through knowledge, and personally through reflection and application of effective characteristics. This enhances the group leader’s confidence which extends to effective group meetings and providing more specialized interventions for the psychoeducational group. Self-awareness of which characteristics are effective and reflecting on which ones best support the group is one vital component as to why self-development is imperative in psychoeducational groups (Newstead et. al, 2024).Confidence adds to building trust and authentic transparency within the group members to help their group members. Empathy, awareness, and flexibility are three positive and effective leadership characteristics that help support growth in psychoeducational groups. The leader should ensure the group members are protected emotionally and physically throughout the psychoeducational group (Brown, 2018). Possessing an empathetic nature creates active engagement between the group leader and the members. Empathy allows group leaders to understand the emotional composition of the group member’s experiences and still provide support (Brown, 2018). This does not occur in one group session or meeting, but rather is a growing process and impactful when utilized effectively. As the group connects through conversation, activities, and other interventions, an awareness of each other’s experiences and the emotions tied to those experiences also transpires (Maaß et. al, 2022). In essence, the group members also develop a deeper self-awareness of others aiding in their own self-development. The transference of learning that occurs in psychoeducational groups gives group leaders confidence to continue developing the group through transparency, interventions, and mindfulness.
Group leadership skills are obtained through practice, application, and experiences. As I recall my experience in various leadership roles, I can identify within myself that developing more of a flexible mindset and mind shift would be beneficial to my leadership characteristics. Many would describe me as a charismatic leader because of the motivation, support and communication I provide in leadership (Brown, 2018). However, when charismatic leaders are put in uncomfortable positions, we tend to worry about how everyone else will feel regarding the change rather than pivoting to make the best choice and demonstrate flexibility. Developing as a leader is part of the self-development process and through experience, knowledge, and awareness, I believe I will continue growing in this area.
Jesus displayed biblical characteristics as well as principles that are applicable to leadership roles. He was humble, showed empathy, and resilience and we are still learning from His experiences. He humbled himself as they insulted Him during the hardest time of His life (New International Version, Mark 15:29-32, 1978). He was the true King and yet He remained humble because He knew He would rise again to save our souls. He also showed empathy to those who others looked over. He healed the sick and the poor and understood their pain (New International Version, Luke 13:10-17, 1978). Jesus never complained because He knew He was doing the work God had called Him to do. As a leader, these qualities are impactful with people, especially people who are searching for help and support. Jesus showed resilience through all the pain, the mocking, the ridicule, the disbelief, and remained sound in His biblical principles. Although He questioned God in Matthew 27:46 (NIV, 1978), “…My God, my God, why have you forsaken me?” and cried out in pain, He held on to God’s promises. The resilience He showed for His people through His own struggles conveys a strength in leadership that empowers others to continue believing and growing.
References
Brown, N.W. (2018).
Psychoeducational groups: Process and practice (4th ed.). Routledge.
Maaß, U., Kühne, F., Hahn, D., & Weck, F. (2022). Group cohesion in group-based personal
practice.
Behavioural and Cognitive Psychotherapy, 50(1), 28-39.
https://doi.org/10.1017/S1352465821000369Links to an external site.
Replies
Students are required to reply to
at least two classmates’ threads by engaging with their ideas in a meaningful, constructive manner. Replies should demonstrate a deep understanding of the coursework, extending the discussion by building on the original post and introducing additional academic perspectives. Replies should also spur critical thinking in peers going beyond simple agreement, this should be done by asking questions for further discussion and bringing in different resources than those used by your peers. The use of the textbook and the Bible is encouraged. Each reply must be supported by at least one recent scholarly source (from within the last three years) and should demonstrate the ability to synthesize your classmate’s ideas with your own, creating an insightful dialogue grounded in evidence-based research.
As you consider the discussion board prompts this week, are there any areas where you either currently experience or anticipate experiencing anxiety related to leading a group? At this point in the class, which type of group would you prefer leading? Provide a rationale for your choice.
Brown: Chapters 4 – 6
Chapter 4
Theories of Group Leadership and Instruction
The Cognitive Component for Dissemination of Information
Major Topics
Theories of group leadership
Theories of instruction and learning
Styles of instruction and learning
Techniques to encourage and promote involvement and learning
Introduction
Psychoeducational group leadership demands that you know how to lead a group and how to teach. Therefore, this chapter presents theories of group leadership as well as theories about how people learn and how to teach. When confronted with having to present or teach something, you may think about what was most effective and what was least effective for your personal learning, using that as your guide for what to do and how to do it. You may even think about individual differences but do not know how to accommodate these. As a leader of psychoeducational groups, this would not be an effective approach. You need to teach and lead based on your audience’s needs and characteristics, not on yours. Therefore, this chapter presents group leadership theory, and you are encouraged to read and learn more about the different ways in which people learn, how to accommodate various learning styles, and the effective ways to present material so that it is learned and retained.
Also very important is your preference for instructional style, as this will be a major determinant for how you teach. For example, if you prefer a lot of movement and activity, you will tend to plan your groups to use a lot of these. Suggestions are presented to help you integrate your instructional style with various learning needs.
Theories of Group Leadership
Theories of group leadership presented here fall into four major categories.
Leaders can be identified by certain traits and characteristics.
Leaders can be identified by a style, such as democratic.
Leadership demands a distribution of actions and is not dependent on one person.
There are different styles of leadership for different stages or group situations.
Traits and Characteristics Theory
Numerous studies have been conducted to identify the traits or characteristics of effective leaders as compared to followers. The results to date do not reveal any clear-cut set of characteristics. For example, Bird (1940) concluded that high intelligence, initiative, a sense of humor, and extroversion were traits of leaders. Mann (1959) reviewed 125 studies on leadership and concluded that intelligence and personal adjustment are correlated with leadership.
Stogdill (1959, 1974) reviewed two sets of leadership studies: studies conducted from 1904 to 1947, and studies conducted from 1948 to 1970. The review revealed two different sets of characteristics, with persistence, responsibility, and initiative as the only overlapping traits. It may be that leaders emerge depending on conditions and the persons available to assume leadership.
Leadership Style/Theories
Group leadership styles and theories can be a guide to developing a personal characteristic approach to leading psychoeducational groups. Styles are usually a result of the leader’s personality and preferences, and theories give a framework to integrate various leadership styles with the abilities, personalities and preferences, and needs of group members. The intent of theories is to show how differing approaches may be needed for various target audiences.
There are several leadership styles; charismatic, person-centered or democratic, autocratic, and laissez-faire.
Charismatic leaders inspire and motivate on the basis of personality alone. These leaders seem to be able to touch something important in a number of people, who are then willing to follow and obey them. They have extraordinary powers of persuasion and communication, and are generally very goal focused.
Person-centered or democratic leadership encourages members’ participation in decision making, the leader shows concern for members’ welfare and comfort, and role differentiation is maintained. This style of leadership is not consistently related to productivity, as more time may be spent on relationships and having input than on accomplishing the task.
The autocratic style of leadership can be comforting to some group members, especially those who are confused, searching for certainty, and have difficulty navigating ambiguity, as this style is firm, controlling, and decisive. This leader has a plan and works to implement that plan with little or no deviations or input from group members. The leader knows what is best for the group and members, is intolerant of suggestions, has little flexibility, and his/her confidence can sometimes border on arrogance.
The laissez-faire style of leadership is very much a hands off approach where the leader provides little or no direction and allows group members to decide what they want to do. In contrast with the autocratic style, this style can set a climate of considerable uncertainty and ambiguity that is very unsettling to group members and can evoke their fears.
It can be helpful to reflect on the usual style of group leadership, or to review the groups that are personally considered as successful to get a sense of what style you may be drawn to or use. Increasing the sensitivity to group members’ needs as well as reflecting on how the variety of styles may be appropriate at different times in the life of the group and/or for different groups can help develop a sense of how to integrate leadership style with the group’s purpose and goals, and group members’ needs. The next section presents some leadership theories.
Distributed Actions Theory
Distributed actions and functions theory perceives leadership as members having vital functions to perform, not just the leader. Leaders provide structure—for example, integrating information, coordinating, and summarizing. It is the leader’s responsibility to provide for the well-being of group members—for example, relieving tension, attending to the emotional climate of the group, and building relationships. Fiedler (1978) proposed a distributed function for group leaders based on group needs. He proposed two functions: task and maintenance.
Task-oriented leaders take responsibility for the direction and functioning of the group. They make decisions and group members are willing to follow. Tasks are clear, unambiguous, and can be structured. Maintenance-oriented leaders concentrate on having members participate in shared responsibility and decision making. These leaders are most effective when the task is somewhat clear (although there may be some ambiguity) and members are willing and able to assume some responsibility for the functioning of the group.
Both functions can be used effectively in psychoeducational groups. Task functions are most important in pre-group preparation and in the beginning stages. As members become more comfortable and trusting of themselves, the group, and the leader, they assume more responsibility for the functioning of the group and the leader assumes a maintenance function. It may take time and experience to know when to shift functions, but both are useful and can be detrimental if used inappropriately.
Situational Leadership Theory
Hershey and Blanchard (1977) proposed a theory of situational leadership that classified leadership behaviors along two dimensions: task and relationship. They used the two dimensions in conjunction with the maturity level of group members. Task behaviors are telling, explaining, and clarifying, and are primarily one-way (i.e., leader to members). Relationship behaviors are those the leader uses to give emotional support and to facilitate group progress. They are characterized by two-way communication.
Hershey and Blanchard (1977) defined maturity in terms of a person’s extent of achievement motivation, degree of willingness to assume responsibility, past experiences, and educational levels. The degree of maturity also is related to the newness or novelty of the task—for example, a highly educated adult may have little or no knowledge of a given task and thus would exhibit low maturity.
These categories produce four interactions of task and relationship, with four related leadership behaviors: (1) high task–high relationship uses telling behaviors, (2) high task–low relationship uses selling behaviors, (3) low task–low relationship uses participating behaviors, and (4) low task–high relationship uses delegating behaviors.
Both of these leadership theories take into account the variations in needs and abilities of group members, the tasks, and the group itself. However, neither describes how to recognize learning levels in the group and what the leader can do to facilitate group development.
Example of Application of a Theory to Psychoeducational Groups
Following is an example of applying the situational theory of leadership to the varying levels of members’ learning capabilities and/or to the stage of group development.
Low-Level Abilities—High Leader Tasks
When group members are behaving at a low level, as is seen in the beginning stage of group development, the leader needs to be more task oriented and do more directing and structuring. Decisions about what to do and how to do it are beyond members’ capabilities at this point. All group members are dealing with issues of safety, trust, inclusion, and competence, regardless of their educational or experience level. Explaining, clarifying, and reflecting are useful for reducing ambiguity and answering unasked or indirect questions about the real issues. Some members may be so fearful that they never move beyond this level. Leaders should neither push them nor expect more than they can do.
Low to Moderate Level—High Leader Task/High Relationship
When group members reach a low to moderate learning level such as what happens as the group develops, some of their real issues have been sufficiently addressed, so less resistance is encountered. Members appear willing to give the leader and group process a chance to meet their needs. Participation is still tentative and there is an air of wariness, but many members mask these feelings and wear a facade of cooperativeness and involvement. Leaders can increase participation and involvement by encouraging and motivating.
Again, the major focus is not on the task but on the indirect and unspoken feelings of group members. Nonverbal behaviors are useful here. Eye contact with head nods, a slight forward lean, warmth, and showing interest and respect can contribute to their feelings of being encouraged and motivated. Leaders should plan activities that can be easily understood and accomplished with little or no frustration. Leaders will be very active and busy with group members at this level, as responses need to be immediate and directed to individuals.
Moderate Level—Low Leader Task/Low Relationship
Few group members begin a group at the moderate level. If there are members at this level when the group begins, the group leader will find them to be of immense help. Their modeling of desired attitudes and behaviors, confidence in the process and the leader, and willingness to participate promote feelings of trust and safety for other members.
However, most groups will not have this benefit. The good news is that the group can get to this level in a short time by facilitating the process to build confidence in the group process and leader while attending to group members’ safety and trust issues. Once this level is attained, the leader can become less active, since members will interact with each other more and communication will not be primarily to and through the leader.
High Level—Low Leader Task/Low Relationship
When participants reach the high level, they can effectively function independently as team members. This level is attained over time with considerable interaction of members. They have to know each other well and feel accepted, cared for, and respected. Leaders can facilitate this process, but it cannot be hurried. Each and every member might attain this level, but some members will take longer to arrive than others. Group leaders must take care not to become discouraged when a group fails to reach this level. There just may not have been enough time.
Learning Preferences and Leadership Strategies
Leaders of psychoeducational groups need to use a combination of learning theory and group development. Theories of learning, including principles of instruction, provide a framework for presenting material for the intended audience so that they can understand it, apply it, and retain it. Theory presents a basis for learning and suggests strategies. Knowledge of group development allows the leader to make optimal use of techniques and strategies. Group development stages suggest when and how to present material so that it can be effectively received and used.
Table 4.1 presents an overview of the preference for learning approaches and activities most often encountered in psychoeducational groups. These are presented as personal preferences, and completing the scale will not only help identify your personal preferences, but will also help identify other preferences that group leaders will have to accommodate when leading a group. Beginning group leaders may tend to use their preferred learning approach and not make sufficient use of other preferences that could be reflective of those for some group members.
These preferences were developed using theories of learning and stages of group development. They are not dependent on members’ intelligence or amount of education, although these factors may come into play for the advanced levels. The table presents simplified ways of identifying preferences, associating them with behaviors, and suggesting leadership strategies. It is strongly recommended that readers learn more about typical behaviors expected at different ages, and in different stages of a group, and to integrate this information with your preferences for learning. The learning preference clusters derived from the scale are also used to identify instructional strategies presented in the next section.
Table 4.1 Learning Preferences Scale
Directions: Rate yourself on the items using the following scale:
5 = Considerably like me; 3 = Somewhat like me; 1 = Not at all like me. 4 = Very much like me; 2 = A little like me;
1. I enjoy and learn from sharing information in a small group.
2. I need to see a personal connection in order to learn.
3. Pleasing other people is important to me.
4. Pleasant relationships and harmony are highest in my priorities.
5. I have difficulty accepting criticism.
6. I like to get things settled and finished.
7. I need to know what to expect, and I do not like surprises.
8. There is a “right” way to do things, and I want to do that.
9. It bothers me if things are not orderly, organized, and systematic.
10. I value structure and predictability.
11. I am often spontaneous in my actions.
12. I begin many projects but do not always finish them.
13. I put off doing tasks but can accomplish much in a burst of activity.
14. I enjoy dramatizations and like to perform.
15. I am curious about many things.
16. I tend to work better independently than in a group or team.
17. I am not good with chitchat or small talk.
18. I value having information presented briefly and concisely.
19. I am very task oriented.
20. I very much need to know why and how something is done, or how it works.
21. I am intrigued by tasks that call for me to use my imagination.
22. Routine bores me.
23. I tend to work in spurts of energy and activity.
24. I very much enjoy learning something new.
25. I am not as attentive or concerned about facts as I should be, and I sometimes get them wrong.
26. I like to use what I already know instead of learning something new.
27. I prefer that material be presented step by step.
28. I enjoy tradition, rituals, and custom.
29. Experience is more important to me than theory.
30. I am good with details.
31. I prefer individual activities to group ones.
32. Ideas energize and intrigue me.
33. Disruptions annoy me.
34. I am good at screening out distractions.
35. I am often accused of not communicating my thoughts and feelings.
36. Variety and action are important to me.
37. I enjoy talking about ideas, and it helps to clarify them for me.
38. I get a lot of energy from being with other people.
39. I am impatient with long and slow projects.
40. Many times, I act before I think.
Scoring: Items are clustered as follows. Add your ratings for each cluster.
Personal relationships
Items 1–5
___________
Consistent–precise
Items 6–10
___________
Flexible–spontaneous
Items 11–15
___________
Logical–rational
Items 16–20
___________
Creative–imaginative
Items 21–25
___________
Factual–realistic
Items 26–30
___________
Reflective–thoughtful
Items 31–35
___________
Energetic–distractible
Items 36–40
___________
Table 4.1 is more useful if these points are kept in mind:
Age plays a role but is not critical in determining participants’ preferences for learning activities.
Members may benefit from more than one learning preference.
The leadership strategy must be consistent with the leader’s personality, but all leaders need to use some form of each leadership strategy.
Interpretation of Scores
Identify your top three clusters and your bottom three clusters. These behaviors and attitudes impact your leadership style for psychoeducational groups—for example, if your top three clusters are logical–rational, creative–imaginative, and reflective–thoughtful, your leadership style tends to emphasize individual participation, being task oriented, incorporating new and imaginative materials, being skimpy on presenting facts, and getting irritated with interruptions.
Next, identify your lowest three clusters. You will encounter these behaviors and attitudes with some group members and you need to take them into consideration when leading a group. You need to be able to understand and handle them, not discount, ignore, or dismiss them as unimportant—for example, if your three lowest clusters are factual–realistic, consistent–precision, and energetic–distractible, you should design your group activities and leadership style to accommodate some of these behaviors and attitudes, such as attending to the need for personal perspective, valuing relationships and harmony, presenting material step by step, minimizing theory, and including variety and action. For a brief description of clusters, see the section on “Leadership Strategy Clusters.”
A leader must have confidence and trust in the group process and in the group members in order for this level to be satisfactory. They must relinquish some power and control and let members assume some responsibility for the functioning of the group. This means a switch in strategy and roles, becoming less directive and structuring and more mutually participatory.
Leadership Strategy Clusters
Personal Relationships
Leaders and group members who score high for this cluster of items show a tendency to perceive, learn, and appreciate in terms of their personal value system, and making personal connections is very important to them. They are not motivated or intrigued by an intellectual or cognitive approach until the personal connections and associations have been made.
Thus, people who score high on this cluster may tend to overemphasize harmony, pleasing others, and other such relationship issues. Group leaders may ignore or dismiss any signs of conflict, alternative approaches, and suggestions, and may minimize the educational component.
Leadership Facilitation Suggestions: Emphasize establishment of universality; encourage interactions among group members; and monitor personal behavior that ignores or avoids disagreements, dissension or differences of opinions, values, and the like that emerge in the group.
Consistent–Precise
Leaders and group members scoring high on this cluster of items value order, predictability, and a sense of accomplishment—they like to finish things. These characteristics allow them to plan and organize well, and can be valuable assets for creating a psychoeducational group. They do not care for surprises and work hard to ensure that they are prepared for contingencies.
This insistence on order may lead them to overemphasize structure at the expense of spontaneity, creativity, and flexibility. Since groups are unpredictable, these leaders may try to exert more and more control and become very frustrated when these efforts are not successful.
Leadership Facilitation Suggestions: Pay attention to the group and its needs, be willing to institute some modest changes when needed, and try to constantly stay in tune to group process.
Flexible–Spontaneous
Leaders and group members scoring high on this cluster get excited about new ideas, projects, and the like, but may fail to follow through until completion. Their excitement can be contagious and can energize the group. Leaders’ on-stage persona can also be enticing and interesting, which is an asset for engaging group members. However, there may also be a tendency to become distracted by something new and exciting, which can lead to losing the focus for the group. There can be many surprising things that emerge in groups, and group leaders will be accepting of these and easily capitalize on them. The real drawback, however, is that they may try to follow too many new leads, and the original goal and purpose get lost.
Leadership Facilitation Suggestions: Develop and write a plan for each session, review and make changes when needed for addressing what emerged or seemed to be important in the previous session, and make a mental commitment to stick to the plan. Monitor the tendency to be spontaneous as group members seem to prefer consistency and predictability.
Logical–Rational
Leaders and members interest is captured by ideas that trigger their thoughts. They may be reserved and cautious when someone tries to engage their feelings or connect to them on a personal level before they have time to think things through. They like to see logical progressions and patterns, and can be very analytical. Leaders and these group members try to make sense of their experiences by thought and logic.
When the leader demonstrates this kind of reserve at the beginning of the group, this can lead members to feel that the leader is detached, does not care about them, and lacks interest. Although it may makes perfect sense to the leader to begin groups by spelling out the task and rationale, some members can feel that the leader is being demanding and insensitive to their needs. Group leaders will have to take care to incorporate interpersonal connections at the beginning of the group and to learn how to reach out to others in a way that they can feel connected.
Leadership Facilitation Suggestions: Start groups with activities that promote introductions, similarities among group members, and exchanges of relevant personal information between group members before presenting rules and other information. During group sessions respond directly to individual group members, provide empathic responses, identify and express relevant feelings, and effect empathic failure repairs.
Creative–Imaginative
These group leaders and members who score high on this cluster tend to become interested when their imagination is triggered. They live in a world of possibilities, and they want to explore them. They are less intrigued by relationships, routine, cautiousness, and the like, although they do see their value. They just do not want them as their guide or first priority.
These group leaders will be energetic in planning imaginative and creative activities for the group, but may get so caught up in these that they neglect the structure and details that help groups to to be successful. Because they are energized by activities, they may tend to overuse them, and neglect the cognitive component.
Leadership Facilitation Suggestions: Stay emotionally present in sessions, reduce or eliminate speculative thoughts and the like in session and consider these when reflecting on the session’s material that emerged, monitor the use of experiential activities and keep the number used to a minimum, and structure the group around group members’ needs and not your personal needs.
Factual–Realistic
Leaders and group members who score high for this cluster tend to be very much the opposite of the creative–imaginative person. They are grounded in facts and reality, and may not see the need or value of flights of fantasy that imagination produces. They tend to like a reality check and are very aware of what needs to be done.
Group leaders may get impatient with group members who seem to be unrealistic and dismissive of facts and instead, insist on being imaginative. This leader wants an orderly progression for their groups and can be dissatisfied when things do not go according to plan. They may tend to overly rely on structure, guidelines, and lectures, and to minimize discussion, exercises, and flexibility.
Leadership Facilitation Suggestions: As suggested for the creative–imaginative cluster, structure the group around members’ needs, also use a variety of methods, techniques, and strategies, and develop patience with group members’ progress, accept their differences and learn to appreciate the value of differences.
Reflective–Thoughtful
Leaders and group members who score high on this cluster tend to rely on their inner world, as it is very important to them and is the source of their energy. They value contemplation over action and can be patient with the unfolding process for learning and growing. They prefer to think things through and can take time to do this.
Groups can be difficult for this leader as there is a lot of activity, talking, and other distractions from their reflection. They may think when they notice that members become restless that the members do not understand the value of thought and reflection. They may forget that people learn in different ways and that leaders need to provide a variety of learning experiences.
Leadership Facilitation Suggestions: It may be a challenge to consistently remain emotionally present in sessions, but that is what will be best for the group and its members. It is more effective if the reflection occurs after the group session. Stay focused on the group’s process and try to discern the theme for the group and individual group members’ needs.
Energetic–Distractible
Group leaders and members have a lot of energy and enthusiasm, which can be contagious, and other group members can respond in kind. There is an excitement that can make the group interesting for members and get them quickly engaged. These leaders can carry a group along with their personalities.
The other side is that these leaders may be easily distracted and keep things on a superficial level because of their need to keep things energized. They may conduct the group skipping from one thing to another without allowing sufficient time for understanding to develop. It will be very helpful for these leaders to learn how to contain and manage their needs and interests so that they do not become impatient with members who need time to reflect and think.
Leadership Facilitation Suggestions: It can be very important to develop a session plan and to not deviate from this much of the time. Try to not become distracted and begin to follow tangential issues and thoughts. Use the energy brought to the group to encourage and inspire group members to take needed actions and/or to make changes.
Basic Principles of Learning
There are several factors that affect the process of learning, including individual factors, methods, meaningfulness of material, transfer of learning, and retention. The primary individual factors are intelligence, age, previous learning, motivation, and anxiety. Methods are described as active participation, distribution of practice, knowledge of results, and whole versus part learning, and suggestions are provided for uses. Meaningfulness of material discusses associations and organization. Transfer of learning presents some concepts relative to using old learning to learn new material.
Individual Factors
Intelligence level is a combination of innate and acquired competencies. Worchel and Shebilske (1992) defined intelligence as “the capacity to learn and use information.” There are many theories of intelligence, and readers are encouraged to explore them further.
Age and maturation also play a role in learning. Individuals cannot learn before they are ready to do so, and the interaction of age and maturation contributes to readiness. Learning is hierarchical in nature—that is, knowledge builds upon previous learning and is interrelated. Some readiness for learning relates to motivation, but some (especially for children) is dependent on age and maturation.
Education level contributes much to learning. How much a person has already learned relates significantly to his or her ease and speed in learning new material, particularly if the new material relates in some way to the material previously learned. For example, learning applications is easier if principles have already been learned.
Motivation to learn is a complex and abstract concept. Maslow (1943) and Murray (1938) proposed needs as motivating influences. For Murray, needs were psychological in nature, such as the need for achievement. Maslow organized needs into a hierarchical system, beginning with basic physiological needs (such as food, water, sleep, and oxygen) and progressing to self-actualization needs (the desire for self-fulfillment). Other motivators include drive determinants, goal seeking, interests, incentives, and reinforcements.
The level of anxiety experienced by an individual also influences his or her learning. Fear of failure, lack of self-confidence, degree of self-efficacy, and their reversed counterparts (e.g., anticipation of success, self-confidence, etc.) affect the ability of the individual to learn. It is not always possible to determine which response will be elicited by anxiety. For example, fear of failure may elicit a response of hopelessness, resulting in an unwillingness to try to learn new material. Or, people who fear failure may have a reverse response where they try harder so that they will not fail. Previous experiences of success or failure can be projected onto new situations, which influences how the individual responds and is able to learn. Emotions experienced during a particular learning experience also are important determinants of outcomes.
Methods
The presentation of material is important in learning. Even with the large variations in individual ability and willingness to learn, there are optimum methods that enhance the effectiveness and efficiency of learning for most people. These methods also influence retention, recall, and transfer. Among the major methods are active participation, distribution of practice, knowledge of results, and whole versus part learning.
Active participation enhances people’s ability to learn (Lewin, 1944; Brown, 2016). This appears to be true for cognitive as well as psychomotor tasks. Taking an active role promotes better understanding, retention, skill development, and applications. Paying attention, thinking about presented material, searching for patterns and relationships, asking questions, making comments, and practicing skills are examples of active participation.
Suggested Strategies: Discussion, experiential activities.
Distribution of practice is another important factor. Learning, particularly learning a skill, is more effective if practice time is sufficiently long and is arranged so that there is continuity between cue and response and between response and reinforcement. Sequencing tasks, frequent practice sessions, and an emphasis on speed over accuracy are important when teaching skills.
Suggested Strategies: Introduce the new skill, provide time for practice, and practice the skill at each session.
Knowledge of results (i.e., feedback) is an important component of learning. The learner is encouraged when he or she receives input. The input can be either to affirm correctness or to identify and correct errors. Knowing how someone is doing can increase his or her time on-task, thereby increasing learning.
Suggested Strategies: Set a collaborative goal for achievement and the steps needed to accomplish the goal. Openly acknowledge successful steps members take toward the goal.
Whole versus part learning refers to seeing how the part fits into the whole. Although people must learn discrete units in order to know the whole (as the keyboard and commands must be learned in order to use a software program), learners do better when they are presented with the whole before dealing with the discrete units. Orienting and reviewing the entire task allows them to better understand how each discrete unit fits and its utility. Breaking a task down into manageable units allows learners to focus, to avoid feeling overwhelmed, and to deal with one thing at a time.
Suggested Strategies: Guide members to create/write an action plan for changes that include objectives, specific steps that can be recognized as accomplishments, and a timeline for each step.
Meaningfulness of Material
Learners are more motivated to learn and participate if the material has meaning for them. Learners retain and understand material better when the material has significant associations for them. Associations with previously learned material, with internal needs or drives, or with emotional content contribute to meaningfulness.
Organizing material into conceptual categories can help the learner to see significant associations, particularly with previously learned materials. Humans appear to favor patterns and relationships, so it is helpful for their learning if the presenter takes time to ensure the meaningfulness of the material.
Suggestions: Involve members in the decision as to what they think would be most meaningful for them to learn and structure some sessions around their suggestions.
Transfer of Learning
Gagné (1965) described two types of learning transfer: horizontal and vertical. Horizontal transfer occurs when the learner can perform a new task at about the same level of difficulty as an old task. Vertical transfer takes place when old concepts or learning are used to learn or understand more complex concepts.
Suggestions: Ask group members to reflect on their inner resources such as persistence, their skills and other attributes and characteristics that they can use to make changes or to reach their goals.
Principles of Instruction for Psychoeducational Groups
Learning theories provide a framework for determining principles to guide instruction for psychoeducational groups. The same principles relate to instruction in more formal settings, but they are used somewhat differently for psychoeducational groups. Knowing how people learn, retain, and transfer material can help the leader develop strategies for presenting information in a group.
The educational component for most psychoeducational groups is significant; in fact, it is typically emphasized the most. Teaching participants specific information, strategies, and skills is a primary goal in most groups, so developing instructional strategies to maximize learning is a major task for the leader. Table 4.2 presents the primary principles and leader tasks in psychoeducational groups: goals, readiness, motivation, active versus passive involvement, organization, comprehension, and practice. Each principle component is also discussed.
Table 4.2 Principles and Tasks
Principle of Instruction
Leader Task(s)
Clear goals
Develop reasonable goals; review goals with participants; obtain commitment to goals from participants.
Readiness
Understand educational, maturity, and age levels of participants; develop goals, etc., based on participants’ levels.
Motivation
Understand the role of personal needs, etc., in motivation; plan activities to meet needs.
Active vs. passive involvement
Provide for participants’ active involvement; use experiential activities, games, simulations, etc.; encourage questions and discussion.
Organization
Plan for new material to be associated with previously learned material; present whole before part; organize presentation to be hierarchical; material should be meaningful.
Comprehension
Make significant connections of materials to participants; illustrate significance, meanings, implications, and applications.
Practice
Provide opportunities for repetition, review, etc.
Goals
The leader of a psychoeducational group usually develops the goals for the group, particularly for the educational component. These goals should be specific, clear, direct, and unambiguous. They should be developed with the needs, readiness, and motivations of participants in mind. This may be somewhat difficult, as the leader may know little or nothing of the participants as individuals prior to the first group meeting. However, the leader will know some general things that can provide suggestions about the learners’ characteristics. For example, if the group is focused on time management for engineers, the participants are most likely to be college educated, and over 21.
In addition to developing clear goals, the leader must review these goals with participants and get agreement to work toward them. The leader should review the goals with participants at the beginning of the session and ask if they seem appropriate, what changes they might suggest, and if they can agree to work toward them. For groups with involuntary members, the leader may decide to have participants sign a contract to work on the goals. This has been shown to be particularly effective with children and adolescents.
Readiness
The lack of knowledge about participants makes this factor difficult for the leader. Members usually are not prescreened, and the leader typically is not provided with records or background data for most groups. Exceptions may be involuntary participants for some groups (such as those focused on anger control).
However, the leader usually knows some general characteristics of members from which he or she can draw inferences about the readiness of participants for certain activities—for example, in preparing an adolescent social skills training group for boys, the leader can reasonably infer that the members lack certain skills, will likely be either silent or very active because of embarrassment or anxiety, may not have volunteered for the group, may be wary and suspicious of authority figures, and may lack maturity for their age. The leader of such a group might need to address safety and trust issues, “sell” members on participating, and present material more slowly.
Motivation
Motivation may be external (i.e., in the form of a reward) or internal (i.e., by satisfying a need). Generally, the leader can expect that members will have or need both kinds of motivation. If the psychoeducational group does not provide mechanisms for achieving both or either, the leader will find the group difficult, and little or no learning will take place.
Since there usually is no pre-group interviewing, the leader typically does not have the opportunity to get input on participants’ motivators. Some may be evident, such as the wish to avoid incarceration. Others, such as a need for achievement, are internal processes that must be inferred from behavior over time or by self-report.
The leader can make accommodations to provide motivators or to encourage group members’ self-motivation. Planning activities to encourage participation by motivating is the first step.
Younger participants typically respond to tangible rewards (e.g., candy). Older participants like tangible rewards as well, but they also want to know what participation will do for them. A motivator may be provided by outside forces, such as an employer. Accessing internal motivators is somewhat more difficult. Leaders can review the proposed schedule and activities and obtain input from participants on how well the planned activities meet their individual needs, request additional suggestions and incorporate them, or allow participants to help set the agenda.
The most important step a leader can take is to understand the developmental levels of participants, the background of the condition (such as anger and violence), strategies generally found to be successful, and the role of motivation in learning. Reading the literature can provide some needed information.
Active Versus Passive Involvement
Active involvement enhances learning. Hands-on activities promote learning by doing. Active participation includes group members responding in a discussion, role-playing, drawing, writing, talking, and engaging in movement. Less learning takes place with passive participation—for example, by listening to a lecture.
The leader has more control over this factor than over most others. He or she is responsible for planning and designing the learning experiences, which provides the opportunity to ensure that the activities encourage active participation.
Another responsibility of the leader is to encourage questions and discussion. The “Questioning Skill Development” section in Chapter 2 gives more information on how to use questioning effectively and on how to respond to questions from participants.
Organization
It is essential that the material being presented is organized in such a way that it is meaningful, can be associated with previous learning, is hierarchical, and is appropriate for the allotted time. Careful thought and planning promote good organization.
Organizing materials for a largely unknown audience is not easy. Even when the leader has relevant information about participants, organizing is a challenge. Most leaders over-prepare and have more materials and activities than can be covered in the available time. This is preferred to underpreparing, however, because it is much easier to discard material than to stretch material out. There also are groups that will explore topics or activities in more depth for unknown or unanticipated reasons. A leader is well advised not to truncate the extended exploration if it is beneficial. If members appear to be getting more out of the in-depth exploration than they would be out of the next planned topic or activity, this is reason enough to stick with it.
Transition from one activity to the next should occur before boredom and disinterest appear. There must be adequate time to process activities, but you should not linger over a topic too long. A good sequence to follow in a group session is a short lecture or presentation; questions and discussion; exercise, role-play, game, or simulation; processing of activity; and summarization. Even a short one-time session can use this sequence. For additional information, see the section on “Taxonomy.”
Comprehension
The leader should provide many examples, illustrations, and descriptions for concepts and other significant material. These help participants learn through association and repetition. Often, the leader does not know participants’ comprehension needs and levels. Giving examples helps increase the probability of making significant connections for most participants.
When applications are important, it is helpful to have several illustrations or examples. It also is helpful if participants can provide additional examples or make suggestions. The most important thing to remember is that meaningfulness of material promotes and enhances learning.
Taxonomy
Bloom et al. (1956) developed the cognitive domain for the Taxonomy of Educational Objectives, and this is still useful for establishing instructional goals. These are hierarchical and provide a framework for sequencing and organizing material. The cognitive domain has six levels that call for thinking to move from simple to complex:
Knowledge. The first level includes thinking activity focused on recall of specifics, universals, methods, processes, patterns, facts, terminology, trends, principles, and generalizations.
Suggestions: Be sure to define terms even if you believe that participants are familiar with them. Be specific about principles, concepts, and so on that are part of the presentation. Be cautious in making assumptions about what participants already know.
Understanding. The second level incorporates and extends knowledge to include interpretation, translation, and extrapolation.
Suggestions: Leaders can get feedback from participants about their levels of understanding. This also gives an opportunity to fill in missing information and to correct misunderstandings and faulty knowledge.
Application. Level 3 provides for selective use of abstractions (formed from knowledge and understandings) in particular situations.
Suggestions: The leader can present applications after presenting facts and giving feedback on the participants’ understanding of the facts. Participants who can suggest appropriate applications demonstrate successful completion of levels 1 and 2.
Analysis. Level 4 cognitive processes include the ability to see discrete elements as well as the whole.
Suggestions: Analyzing relationships, patterns, and organizing principles are examples. Analysis involves a relatively high degree of knowledge and experience with the topic, so the leader may be the only one at this level.
Synthesis. Level 5 incorporates the previous four levels with the creation of a different or new perspective, product, or process.
Suggestions: This level of learning would be somewhat unusual for the purposes or goals of most psychoeducational groups. Groups that have a problem-solving focus may achieve this level. Groups that have personal issue involvement as a primary component may see some members reach this level, especially if the group runs for several sessions.
Evaluation. Although this is considered the highest level for cognitive processes, evaluation can interact with all of the other levels. It is defined as making judgments about strengths and weaknesses, positive and negative points, adequacies and inadequacies. The interaction with other levels can help increase accomplishments at those levels.
Suggestions: Evaluating the adequacy of knowledge on a particular topic can lead to more in-depth information being sought or given.
Techniques
Psychoeducational groups employ a variety of formats, making it difficult to name a specific set of techniques for instruction and learning that are applicable to all. The variety of participants and their characteristics and the range of educational emphases provide additional confounding variables. Therefore, the techniques described here are not necessarily the preferred methods, but they give a sense of the variety of techniques that can be used.
The leader of psychoeducational groups can use several different techniques that will be effective. Experience promotes understanding of when to use what with whom and expected outcomes. Using these techniques to their best effect is a major thrust of this book, but the most effective group leaders also learn from their own experiences. Some techniques were presented briefly in Chapter 1, but are described in more detail in this section.
Lectures
To be effective, lectures should be well-organized presentations that lead the listener from point to point to provide an integrated knowledge and understanding of the material. Lectures are efficient ways of getting across a large amount of information in a short amount of time.
However, lectures have several drawbacks:
Listeners tend to have short attention spans unless the topic and presentation grab and hold their interest.
Listening to a lecture is a passive form of learning, which is less effective than active forms.
Lecturing demands considerable planning, organizing, and presenting on the part of the leader.
If a leader plans to use lectures as part of a psychoeducational group, he or she should use mini-lectures lasting no more than 20 minutes. These are most effective if kept to 10 or 15 minutes. Members are more inclined to listen for that period than for a longer span. Further, having several mini-lectures interspersed with activities to reinforce the material will lead to more learning and retention. The leader also should restrict the amount of material to that which members can use.
Discussion
This technique can be used to promote active involvement. Lively discussions contribute interest to the session and encourage participants to be involved. Discussion as a technique can be differentiated from discussion groups, where the main purpose is to engage in discussing. As a technique, discussion is not the goal of the group; it is typically kept short so that other activities can happen. Fewer members may be involved, and members tend to talk to the leader rather than to each other.
Leaders can initiate discussion by asking questions, calling for comments or questions, and encouraging exploration of points, issues, or concepts. The exchange of ideas, opinions, and experiences can be energizing to the group. Members feel their input is valued and that they have something to contribute.
Activities
Activities, games, simulations, and role-play are forms of experiential learning. They are designed to produce more active involvement on the part of participants, to focus on and emphasize a particular point, and to provide an opportunity for affective as well as cognitive learning.
Experiential groups constitute a major category of psychoeducational groups, and there is some overlap with skills training. When exercises or other forms of experiential learning are used, members can integrate affective and cognitive learning, which contributes to and intensifies retention.
Several specific strategies should be employed to ensure safety for group participants, since experiential learning can arouse unexpected and uncomfortable feelings. The leader must have the expertise to help members deal with these feelings, which can be intense, and to plan sessions so that the likelihood of arousing these intense, uncomfortable feelings is minimized.
Exercises and games can be fun as well as educational. When learning is enjoyable, motivation is increased, comprehension is enhanced, and retention is promoted. Planning, conducting, and processing experiential group activities were discussed more fully in the “Planning Experiential Group Activities” section in Chapter 3.
Media
Movies, audiotapes, and videotapes, computer presentations, and slides are examples of media. Media cover a large amount of material in a short time. They tend to capture interest more easily, can provide visual illustrations of material, and have been demonstrated to be effective in learning. The primary disadvantage of media is that they do not actually involve the learner. (The exception may be computers, but that still depends on what is being presented via the computer and if the learner is expected to interact with the machine.)
The leader of psychoeducational groups should make judicious use of media. Used as accents or lead-ins, media presentations can be quite effective. Used too frequently or for too long a time, however, media presentations are ineffective. Timing is important as well; having participants passively watch a video immediately after lunch, for example, is more likely to induce sleep than to promote learning. Plan for media to be an enhancement, not the primary technique.
Discussion/Reflection Questions
Describe the procedures that could be used to encourage retention for children, adolescents, and adults.
Develop a list of specific strategies that would be helpful for each style for adult learners.
Identify your preferred learning style and helpful strategies for this style. Share these in a small group, and make a list of the different styles and strategies present in that group.
Chapter 5
Group Leader Self-Development
Major Topics
• The leader’s personal growth and development
• Reduction of self-absorption
• Effective group leader characteristics and attributes
• Becoming mindful
Introduction
Some group leader skills, such as attending, are relatively easy to learn. Others can be learned with practice and feedback, such as active listening and responding. However, none are effective without the art factors for group leadership, and these cannot be taught; they have to be developed by each person individually. For example, the nonverbal behaviors that portray warmth and caring can be taught, but warmth and caring cannot be taught since these traits come from the inner self. The skills are important, but the self-development is also important, regardless of the kinds of groups or the theoretical orientation.
This chapter presents the rationale for continuing personal development to increase effectiveness as a group leader. Also presented are descriptions for basic characteristics that help group leaders establish core conditions, such as warmth and caring; how skills used with individuals also have applications in group settings; and group level skills such as linking.
Although much of the emphasis is on skills, the art factors of group leadership contribute significantly to its effectiveness.
Mindless use of techniques and skills is not helpful for group members. These can give the illusion of progress and growth, as there can be much activity. But, if there is no understanding that accompanies the use of techniques and skills, the most important part of learning for group members will be lost. It is strongly recommended that group leaders become more aware of both their inner experiencing and of external events that are occurring simultaneously in the group, and use this information for the benefit of the group and its members. Many of the personal development exercises are designed to guide you to better understand your inner self and to further develop that.
Rationale for Personal Growth Emphasis
An integral part of any preparation as a group leader is his/her personal development. This is very important for both the leader and for group members. It plays a significant role in preventing burnout and countertransference as well as promoting skill development, knowing and understanding what to do in sessions, providing a deeper and better understanding of group members’ issues, and increasing confidence for the group leader. The literature is clear that the group leader’s personal development impacts the work with group members in direct and indirect ways.
At the beginning, it may be difficult to understand how working on personal development will result in helping the group, however, in time, the group leader will realize that they are gaining a deeper understanding of the issues that group members are facing and how hard it is for them to even just become aware of their personal issues so that they can work on them.
An example may help to highlight the importance of learning more about your inner self, your unresolved issues, and your unfinished business. Answer the following questions:
How do you react to and manage criticism?
Do you become defensive when criticized and deny the charge?
Do you attack the person who criticizes and point out how wrong he or she is?
Do you ignore the criticism and the person?
Do you shrug the criticism off outwardly but seethe on the inside?
Do you agree with the criticism to get the person to shut up?
Do you become hurt and angry but do not say anything?
Any and all of these responses can be easily traced to childhood reactions to criticism from a parent, if not totally, then in some way. This example is only one of many behaviors, attitudes, or reactions that can be traced to past events that influence the behaviors and attitudes exhibited in the present.
Life events also play an important part in determining self-perception. Family of origin experiences and past experiences interact with personality to form self-perceptions about adequacy, efficacy, worth, and value. Your beliefs, attitudes, and values are developed from your family, the larger culture, and other experiences. The more you understand who you are, how you developed, and your relationships, the more you can understand your clients, and reduce the potential for countertransference.
Goals for Self-Development
The following list of leader characteristics and actions are constructive for the group and its members. Most of these rely on the extent of inner development for the group leader, and are a part of their growth, and are not skills that can be taught and learned. Prospective group leaders can be made aware of the need and positive outcomes for these characteristics and actions, and can be guided to develop them.
Confidence, not arrogance—Having confidence is an asset. However, when confidence becomes arrogance such as thinking that you know what is best for someone else, or feeling superior, then it is counterproductive for a therapeutic relationship.
Setting the frame for the group—Groups develop safety and trust when they can have confidence that the leader will protect and guide them. The frame is a combination of verbalized structuring, and the nonverbal behavior that conveys attributes and characteristics such as genuineness, caring, and the like.
Managing and containing affect—Group leaders have to be able to model managing and containing their personal affect so as to not displace this on group members. In addition, it is helpful to the group when the leader can help manage and contain the group’s affect so that they can do the work they need to do, and can use this in constructive ways to better understand what the group wants and needs.
Respect for boundaries—Group members find it comforting when the leader attends to both physical and psychological boundaries. Physical boundaries include respect for time boundaries by beginning and ending on time, and other actions such as ensuring that the group does not experience intrusions and distractions. Psychological boundaries are more difficult to describe, as these differ from these differ from person to person. However, group leaders must remain aware of the separation of self from others, and work to understand members’ psychological boundary strength.
Providing a holding and containing environment—The importance of this cannot be underestimated, as this is what promotes group members’ feelings of safety and trust, promotes their disclosure, and encourages them to experiment with new behavior in the group. This environment is formed by the extent of the leader’s developed self that is able to be empathic and sensitive to members’ feelings, and an understanding of how they can be guided to grow and develop.
Balancing the cognitive and affective needs for the group—Psychoeducational groups need a balance between the cognitive material and the affective needs of the group. Group leaders need almost an intuitive understanding of how to balance these, as every group, even those that are focused on the same topic or goals, differs in these needs.
Potential for Negative Countertransference
Unfinished business and unresolved personal issues have potential for causing countertransference or transference. Transference and countertransference refer to the process by which thoughts, feelings, and wishes from the person’s past are put on—that is, transferred—to another person. Transference is the term used when the process goes from the group member to the group leader, and countertransference is used when the process goes from the group leader to the group member. Both occur on an unconscious basis, so they may be difficult to identify.
Countertransference can be especially destructive to the relationship between the leader and group members because it can influence how you perceive and react to the client, affect the direction of the sessions, and impair the leader’s ability to be objective. An example may help to clarify this concept.
Suppose you and your mother were very close, but she became ill and died when you were in your early teens. You still feel hurt every time you think about her, and you wish and yearn for her to be with you today. You may have worked through some of your grief, but you still cry on special occasions such as her birthday. A group member who is a few years younger than you tells you how much she detests her mother because the woman is emotionally abusive. As the client is talking, you find yourself becoming angry but try to hide it or suppress it in some way. You listen to the client and nod your head. When you respond, you focus on how the client’s mother may be trying to help her to not go astray or get in trouble, which is why her mother seems to be nagging. You gently chide the client for not being more understanding of how hard it is to be a good parent and she should appreciate what her mother is trying to do. At that point, the group member clams up and seems to withdraw.
This is not a subtle example of countertransference. Issues are buried so deep that reflecting will not bring them to awareness much of the time. There may be numerous life events that have the potential for countertransference, and because it takes place on an unconscious level, you are not aware of when it is happening. Bringing your unfinished business and unresolved personal issues to awareness can do much to prevent countertransference that has a negative impact.
Parental messages from your past may continue to influence your thoughts, behaviors, feelings, and attitudes. You are probably aware of many of these messages but remain unaware of others and their current impact on you. These parental messages did much to influence your self-concept—that is, your perception of your “self.” The way you feel about and perceive your self has its roots in how you were responded to and whether your needs were met by your major caregiver.
Some pieces of your psychological development were influenced by the degree to which you completed other expected developmental tasks, such as separation and individuation, and how your parents responded or guided you through these tasks. Research seems to show that children of depressed mothers do not get the positive encouragement needed to move through these developmental tasks, because these mothers cannot be emotionally present with their children due to the depression. Overprotective parents, rejecting parents, neglectful parents, abusive parents, and absent parents also have an effect on psychological development.
Parents play a major role in the development of your self-concept. How you perceive yourself is, in part, a reflection of how your parents reacted to and perceived you. They communicated in direct and indirect ways their feelings about your abilities and worth; their expectations for your behavior, values, and attitudes; and their satisfaction or displeasure at your ability to meet their expectations.
You also had some reactions and feelings about your parents’ expectations and responses, and it can be important for you to become aware of what these are as they continue to impact your current functioning and relationships. You may find that you are still trying to obtain a parent’s approval, trying to get a parent’s attention, hearing parental disapproval of you in words from others, reacting with hurt feelings to any perceived criticism, expecting to be chastised, competing with siblings for parental love, and trying to get a parent to understand and respond to your feelings.
Self-Absorption or Underdeveloped Narcissism
Narcissism is a focus on the self or love of self. Kohut (1977) not only described in some detail how the self and narcissism develops but also proposed that there is age appropriate for children and adolescents, and undeveloped and healthy narcissism for adults. For example, it is age appropriate and healthy for toddlers to consider almost everything and everyone an extension of themselves, to act as if everything belongs to them and that everyone is in service to take care of their needs. However, it is neither age appropriate nor healthy when an adult feels and acts this way. Kohut (1977) also described healthy adult narcissism and proposed that this is characterized by wisdom, appropriate humor, creativity, and empathy. Less than healthy narcissism has its roots in empathic failures in infancy and childhood where the child’s primitive self was not positively responded to by the primary caregiver, or when the child was expected to take care of and meet the needs of the parent instead of having his or her needs met by the parent.
Everyone can have some underdeveloped narcissism that is displayed in self-absorbed behaviors and attitudes, of which they remain unaware. It can be helpful to be willing to consider that you too can exhibit some self-absorption of which you are unaware, and/or refuse to consider when others point this out to you. Try to not close your mind to the possibility, and if you should identify some personal self-absorbed behaviors and attitudes, use this information to begin to consciously reduce these. This can be positive growth and development.
Self-Absorbed Behaviors and Attitudes
Prior to exploring personal self-absorbed behaviors and attitudes, it would be helpful to describe what they are, and how these can be manifested in the leader and group members.
Examples are provided to describe how the leader may consciously or unconsciously exhibit these in the group and a possible negative effect on the group and/or on some group members. Some examples are also provided for members who exhibit the behavior.
Grandiosity—An inflated sense of self-importance, and a lack of understanding and acceptance of personal limitations. An example of this is a group leader who feels that he/she knows what others should or ought to do, and pushes members to take psychological risks that may be harmful. Group members can exhibit this by giving advice, mostly always feeling overwhelmed with too many activities, and can adopt a superior attitude.
Impoverished self—This is the flip side of grandiosity, and can coexist with it. This is the part of self that feels deprived, unfairly mistreated by others, inadequate, and helpless. An example is when a group leader brings these feelings into the group and projects them on to group members thereby increasing any of these feelings that the members already possess. Group members exhibit this with a “poor me” attitude.
Attention-seeking behavior—A description of this behavior is seen when individuals behave and act in ways to keep them in the spotlight, such as talking loudly, interrupting, or changing the topic to something about them. A group leader can exhibit this behavior when he/she uses a number of sessions to work on the leader’s concerns and problems. Group members do and say things to bring much of the group and leader’s attention to themselves.
Admiration-hungry behavior—While everyone can appreciate being admired, this behavior seeks it most or all of the time, and goes out of his/her way to solicit it, even when it is not deserved, such as what can happen when parents take credit for what their children accomplish. An example of this in the group is when the leader and or members boast and brag about accomplishments, possessions, status, and the like.
Exploitation of others—Using others in ways that violates their boundaries, their independence and separateness, and may not be in accord with their values or best interests. Group leaders can exhibit this in asking for and expecting group members to do favors for them, and vice versa when members expect the leader and/or other members to do favors for them.
Entitlement attitude—An unconscious expectation that he/she must be treated as unique and special, shown preference at all times, and others should accept his/her superiority. An example of this is when the group leader uses group time to get his/her personal needs met, or expects to always be treated as the authority. Group members exhibit this attitude by having an expectation that others are to meet their needs at all times even when these are not verbalized.
Shallow emotions—The emotional life and experiencing is constricted where a narrow range and depth of feelings exist and are accessed. This would describe the group leader who has the words for emotions but does not experience the feelings that accompany the words. The leader cannot be empathic, but can only use words to convey what he/she thinks the other person feels. Group members with shallow emotions tend to only express anger and fear.
Inappropriate humor—Finding humor in other’s discomfort, shame, or difference that is detrimental to the other person. Sexist, racist/ethnic, or other such comments and jokes are examples for this. Leaders and group members can exhibit some or all of the following behaviors that are examples of inappropriate humor: sarcasm, taunting, teasing or other actions that are at another person’s expense and intended to cause discomfort.
Superior and/or arrogant attitude—This attitude is conveyed verbally and nonverbally to show that others are inferior and that this person is superior. Pity, contempt, and suggestions that group members are weak, ineffective, and/or wrong are examples of group leader’s attitudes that convey superiority and arrogance. Group members can exhibit some of the same behaviors and all are intended to convey an attitude of “looking down on others,” comments to show that others are inferior, and they are superior.
Emptiness—Lacks meaning and purpose for life, can feel alienated and isolated. There is nothing at the core of the person’s self. This leader and/or members can substitute activity for reflection on the emptiness, as reflection brings about contact with the nothingness that is terrifying.
Envy—Defined as the conviction that the other does not deserve what is awarded, possessed, given, and the like, and that the envious person is more deserving. The envious group leader or group members can denigrate others’ accomplishments using put-downs and the like, and/or make comments that show that he/she is more deserving.
Extensions of self—An incomplete differentiation of “self” and “not self” as demonstrated by their insensitivity to others’ boundaries. Examples include making personal comments such as remarks about someone’s appearance, touching someone without his or her permission, expectations that others will understand what is wanted or needed without having to verbalize these and provide them without questions. In each instance, there is an unconscious assumption that the other person’s space, possessions, or activities are under the other person’s control and, that they are entitled to violate these boundaries. Remember, boundaries are both physical and psychological, and they distinguish between what is “you” and what is “not you.”
Lack of empathy—This is defined as an inability to reach out and get in touch with what the other person is experiencing, and an insensitivity to others because of the impact their emotions will have on you or because you cannot understand what all the fuss is about. The insensitivity is not always a conscious act.
Examples of a leader’s and/or group member’s lack of empathy include the following:
Changing the topic when others are talking, especially if they become emotional
Expressing false sympathy or empathy
Failure to respond to others
Ignoring what people say when they are talking, especially if they have intense emotions
Focusing only on personal needs
Discounting the impact of an event on someone else
Minimizing the other person’s feelings
Feeling or saying that the other person’s feelings are wrong or irrational
Common Thoughts and Feelings Reflective of the Leader’s Self-Absorption and How to Reduce These
The leader’s undeveloped narcissism can manifest itself in the group in many ways.
Following are some examples of thoughts that reflect some aspects of self-absorption. While most are common and ordinary thoughts that almost everyone experiences, they are also reflective of a self-focus rather than that focus and energy being given to the group and its members. These are also reflective of the leader’s needs, such as a need for approval, that are of more importance to that group leader at this moment than are the group and its members’ needs.
Some common self-absorbed thoughts that leaders can have are the following:
Does or will the group like me?
If I do or say this, I will not be liked.
Am I doing it right?
The group is being stubborn, resistant, unfair, and so on.
Why won’t he/she cooperate?
I’m doing the best that I can, but they are not responsive.
I want him/her to like me.
What can I do that will please the group?
I want the group to think that I am capable, good, competent, and the like.
He/she ought or should _______.
I want to do or say something that will make the group aware, or awed, or sit up and pay attention, or the like.
While all of these are understandable and are not wrong, they are all focused on oneself and not the client or the group.
Reducing and/or Eliminating Self-Absorption
The first step to address self-absorption is to become aware of how you manifest or exhibit the behaviors and attitudes in everyday life. You are probably not aware of these, as they can be a part of you that others see but you are not able to see, you are unaware of how what you do and say convey your self-focus, and/or you did not know of the importance of developing healthy adult narcissism.
Healthy adult narcissism was defined earlier in the chapter as having an appropriate sense of humor, creativity, wisdom, and empathy. This level of self-development calls for a positive sense of self in the world and a sense of others in the world as being separate and distinct from oneself. Healthy adult narcissism is a goal for development and its characteristics can be constantly developing. Following is a scale to get you focused and aware of some possible personal aspects of your healthy or developed adult narcissism, and on some aspects of your undeveloped narcissism that need attention.
Activity 5.1: The Developed and Underdeveloped Self
Materials: A sheet of paper, a pen or pencil for writing, and a copy of the scale.
Directions: Rate yourself on each item using the following scale.
Items 1–5 are related to empathy and the higher your score the more you may need to work to become empathic. Items 6–10 are related to creativity and the lower your score, the more you may want to explore ways to increase creativity in your thoughts and activities. Items 11–15 are related to your sense of humor. The higher your score, the more you can tend to use or respond to inappropriate humor. Items 16–20 are associated with wisdom, which can be described as realizing and accepting your limits of personal control and responsibility, managing personal emotions, and appreciating the value and worth of others. The lower your score indicates that you can work to increase your wisdom. Scores that fall into the mid-range of 10–17 can indicate progress, but there is still some need for further development.
Effective Group Leader Characteristics
The most effective leaders of psychoeducational groups possess certain characteristics and skills. Characteristics refer to what you are and skills to what you can do. Some of these characteristics can be developed, but they must be internalized and become an integral part of the leader’s personality in order to be effective. Skills can be more easily taught, although they may not be easy to learn or to master.
Major characteristics of an effective group leader include the following. These are in addition to the core characteristics of caring, warmth, positive regard, and genuineness.
Belief in the group process
Confidence in yourself and in your ability
Courage to risk
Willingness to admit making mistakes and having imperfections
Organization and planning abilities
Flexibility
Ability to tolerate ambiguity
Self-awareness
Appropriate sense of humor
Belief in the Group Process
A leader’s belief in the group process provides an atmosphere of safety for group members. While the issues may not be openly addressed, many members of psychoeducational groups have safety and trust issues. They wonder if the group will be of any benefit to them, if they will be accepted and respected, and if the leader can take care of them. Leaders who have a deeply held belief in the efficacy of the group provide reassurance to these members on an unconscious level. This reassurance is conveyed in the preplanning the leader does, in how members are prepared for group, in how their spoken and unspoken questions are addressed, by the leader’s ability to contain and manage personal anxiety, and in the leader’s flexibility.
Self-Confidence
Confidence in oneself and one’s abilities is almost self-explanatory. The leader who models self-confidence teaches group members by example. Developing self-confidence happens over time through positive experiences—that is, the quality of your experiences affects your acceptance of your ability for both the leader and group members. For some, positive experiences include approval and praise from others. Group members can respond and grow in positive ways when they receive consistent, positive feedback from many others, such as what can happen in a group, thus, enhancing their self-confidence. Confidence also is enhanced when a member tries out a new skill and the desired results occur. Again, it must be noted that confidence develops over time. Confidence in your group leadership skills also develops over time with appropriate feedback.
Courage to Risk
Taking a risk means being willing to expose yourself to possible failure or to criticism from others, to seek new experiences, to be in error, to grow, and to develop. An effective group leader is dynamic—always growing, always changing. While he or she may be teaching the same content to many different groups, the leader should always be searching for better methods, more participant learning, and so on. Risk taking also comes into play during sessions. Leaders need not be perfect, and sessions sometimes can be enhanced if the leader will take a risk.
Ability to Admit Mistakes
A willingness to admit mistakes and imperfections can be helpful under certain conditions. By admitting mistakes, the leader models an acceptance of self and conveys an attitude of acceptance of others. When you can show that you accept yourself and own your mistakes and imperfections, group members can believe that you will accept them and not expect them to be perfect. This does not mean that apologies are always needed; it simply means that you should own and take responsibility for your errors or imperfections without denigrating yourself, feeling shame, or turning on others and blaming or criticizing.
Being Organized
Organizing and planning constitute a hybrid of characteristics and skills. It is possible to teach organizational and planning skills, but the desire for organizing and planning is an internal one. Effective leaders do considerable work before group sessions to ensure the efficacy of the group for members. Planning and organizing help ensure the safety of members, promote participation, reduce anxiety for the leader and for members, and enhance learning.
How to plan and organize is addressed more extensively in Chapter 5.
Flexibility
Flexibility is a result of confidence and the ability to tolerate your own and others’ anxiety. The willingness to change a planned process or activity is not something that can be taught, but it is a characteristic of confident group leaders. The ability to look at a changing situation and make appropriate adjustments can facilitate the progress of the group. When the group leader lacks flexibility, members may feel stifled, controlled, and overly directed. The flip side is that too much flexibility promotes anxiety, as members are unable to judge what is expected or what will happen next. Striking the proper balance is a learned trait or skill.
Tolerance of Ambiguity
In planning a group, it is useful to know educational level, abilities, emotional concerns, and physical conditions of members. However, since many psychoeducational groups do not allow for prescreening, leaders often do not know much about members prior to the first session, so they must prepare in a vacuum. Furthermore, some groups have involuntary membership and the leader may not even know it. Leaders who feel comfortable and confident in the face of knowing little about members are better able to conduct effective groups.
Self-Awareness
Self-awareness is an ongoing developmental process. It is an important characteristic for leaders of all types of groups. Countertransference issues arise even in psychoeducational groups, and the effective leader knows enough to be aware of personal issues, recognize countertransference when it appears, and understand its impact on the group and on individual members.
Personal ownership of attitudes, behaviors, opinions, and feelings is both a characteristic and a skill. Ownership is a characteristic because it is basically internalized. In order to genuinely take responsibility for your attitudes, behaviors, opinions, and feelings, you must accept that they are yours and are not imposed on you by others. Feeling that someone else has provoked any or all of these characteristics means you are not accepting ownership of them. Mere lip service to assuming ownership is not enough; it has to come from within.
In addition to being a characteristic, there is also a skill component: conveying to others that you accept personal ownership. Another aspect is respect and toleration of differing points of view. Skill in conveying your attitudes, opinions, and feelings in such a way that others do not feel compelled to adopt them is important. Members will be turned off if you come across as dogmatic and as having all the right answers. While members are attending the group to learn, they are not blank slates on which you can write.
Appropriate Sense of Humor
An appropriate sense of humor allows leaders to take themselves less seriously and models for members the ability to see the humorous side of a situation. People who can laugh at themselves usually are healthier than those who cannot. Additionally, seeing the humor in something relieves tension, promotes a sense of playfulness, and contributes to a general sense of well-being.
Group Leadership Attributes
The usefulness of basic inner self attributes of caring, warmth, positive regard, genuineness, empathy, an emotional presence in the group, managing and containing personal emotions, and having a nonjudgmental attitude has been well documented. While there are nonverbal behaviors that convey these attributes, it is difficult to fake them; they must come from within and are an integral part of one’s being. Even in psychoeducational groups, the leader needs to have these characteristics, as they tend to promote learning, which is the goal for these groups.
Caring is shown nonverbally through attending, listening, and directly responding. Physically orienting your body to the speaker, maintaining eye contact, and hearing the meaning (not just the words) all convey caring. However, genuine caring about understanding the other person, and his/her well-being arises from within and is an integral part of who you are. You are able to see your self as distinct and separate from the other person, and are altruistic enough to want to nurture their growth and development.
Warmth is shown through some of the same behaviors but adds a facial expression of appreciation for the other person. Smiles or other appropriate facial expressions convey warmth. Warmth is also generated from within, and is a nurturing attribute.
Positive regard means being open to the speaker and willing to hear his or her point of view without judging the person to be good or bad because that viewpoint is different from yours. Positive regard assumes the worth and uniqueness of the other person, and is a conviction that others are valued and worthwhile as separate and distinct.
Genuineness (or authenticity) is being willing to let yourself be known to the other as you really are: no false pretense; no reluctance to share thoughts, opinions, or feelings; and a real appreciation of the other as he or she presents him/herself to you.
Empathy is emphasized here as the need for the group leader to be empathic, not to just make responses that appear to be understanding. Empathy is not sympathy, as that is a more detached response. Neither is empathy becoming overwhelmed or enmeshed in another person’s feeling where you become lost in their feeling. Empathy occurs when you can open yourself to enter the world of the other person, and feel what that person feels without losing the sense of yourself as separate and distinct from that person.
It is possible and helpful to be able to respond with reflection of feelings and understanding without feeling what the other person is feeling, and this is a skill that can be taught. However, this is not genuine empathy. Think of this as a lower or moderate level of empathic responding. Doing so can be helpful to group members, and that may be sufficient in some instances. Since the capacity to be empathic comes with reduced self-absorption, and a clear understanding of where you end and others begin, it is a reflection of the inner developed self that can clearly delineate and separate one’s self from others and not become enmeshed or taken over by others’ feelings. Developing empathy is a growth process, but is critical and essential to provide the optimum level of group leadership.
Emotional presence in the group is an attribute of effective group leaders. This means that the leader’s thoughts, feelings, attention, and so on, are only focused on the group and its members’ needs during the session. Emotional presence means a lack of thinking about personal concerns, or other such out-of-the-group topics. For example, the leader is not mentally planning for what comes after the group, worrying about a personal problem, or zoning out in some way. This emotional presence of the leader allows for better observation of group dynamics, an understanding of how and when to intervene, attending to group members so as to notice distress or other emotions, and the capacity to realize when an empathic response or repair of an empathic failure is needed. Further, group members are encouraged to believe that they are important to the leader, have worth and value, and these beliefs and feelings are critical to establishing trust and safety, and for fostering self-disclosure.
Managing and Containing Personal Emotions
An essential attribute and skill for group leaders is to manage and contain their personal emotions at times and this is associated with the inner developed self, countertransference, and level of self-absorption. Managing and containing your personal emotions while leading the group not only models this for group members, but also prevents these emotions from being projected onto group members, thus negatively impacting the group on a nonconscious level. It is not unusual for group leaders to have some anxiety, especially at the beginning of the group, or to experience other feelings, such as anger, during group sessions. However, group members can be vulnerable to catching others’ emotions, especially when their psychological boundary strength is insufficiently developed so as to prevent this from happening. Therefore, it is important that group leaders make conscious efforts to manage and contain their emotions so as to not project these onto group members, and/or to reduce the possibility of group members catching the leader’s feelings. A process to manage and contain personal emotions involves the following:
An awareness and acceptance of what is felt.
Sufficient self-development to understand if this is a personal feeling, or if it or part of it is a strong projection from one or more group members that you caught.
If the feeling is personal arising from your issues or concerns, waiting to explore this material outside of the group.
If the feeling is being caught, then either using that feeling to better understand what group members are feeling, and responding appropriately. For example, if the caught feeling is fear or apprehension, group members may be fearful of what can happen in the group, and the group leader can say something like, “it can be scary to not know what will happen in the group.”
The task is for the group leader to refrain from making the group responsible for his/her feelings. Focus on the group and members, don’t focus on or address what you are feeling at that moment, unless you are sure that you are probably containing the feeling for the group. If you are functioning as the group’s container for feelings that are too intense or dangerous or unavailable for them to speak of openly, the leader can use these as a valuable source of information about the group.
Being Nonjudgmental
Another helpful attribute is to be nonjudgmental. Judgmental thoughts fuel emotional responding, and have both conscious and unconscious components. The conscious component is composed of the feelings you have about a person or topic, such as like or dislike, appealing or rejecting, good or bad, and right or wrong. Contributing to these feelings are things like gossip, innuendoes, known facts, influences by others, preconceptions, and personal needs and desires. The unconscious component is composed of the following:
Unresolved family of origin issues
Unfinished business from past experiences
Beliefs, attitudes, values, and the like that are introjected from the family and culture, that help form your countertransference and judgmental thoughts
It is the unconscious component that is the primary contributor to the emotional triggers that can produce intense, and sometimes overwhelming, emotions. What can be helpful to understand is that the judgmental thoughts you can have come from many sources, and can trigger your feelings about the person or topic.
It is important to be able to accept clients as they are, without judging them as good or bad, or right or wrong. You do not have to agree with their perspectives, or accept their values, or approve of their behavior, but you will be more effective if you can suspend judgment, and accept the client as a unique and worthwhile individual. This attribute and skill will significantly contribute to establishing a positive therapeutic alliance, trust and safety in the group, and foster group members’ self-disclosure. Becoming mindful, as described in the next section, aids in becoming and being nonjudgmental, promotes other positive group leader attributes, can reduce the possibility of countertransference, and increases the group leader’s emotional presence.
Becoming Mindful
Mindfulness is purposeful and intentional attention to your here and now, internal and external experiencing. Becoming mindful in the group allows the leader to focus on what is taking place in the group, and with individual group members, without evaluating this as either good or bad, or right or wrong. The leader can just observe without judging and evaluating what he/she is seeing, hearing, and experiencing.
Observation can be more effective with mindfulness, as it enhances experiencing and understanding in the following ways:
Experiencing the present moment while reducing self-absorption.
Concentration is enhanced as mindfulness helps screen out distractions.
Leaders are assisted in staying open, nonjudgmental, and non-evaluative.
Awareness of self and of others is expanded.
It can be a form of emotional regulation and control.
Tolerance of silence is increased.
There are numerous benefits for the leader and thereby for the group when the leader is mindful.
Helpful for monitoring countertransference.
Increases awareness of the leader functioning as the container for the group’s emotions.
Assists in tuning in to group process.
Promotes concentration and emotional presence.
Focuses on immediacy and the here and now.
Helps separate thoughts from emotions and physical sensations.
Monitors and manages the leader’s personal emotions.
Aids in concentration and focusing.
Increases listening ability, which can then help increase empathic responding.
Activity 5.2: Practice Mindfulness
Mindfulness is being aware in the present moment of yourself and of what you are experiencing without criticism, judgments, evaluations, or resistance. So, as you practice the mindfulness exercise, try and let go of worries, plans, and the past and/or the future, and just be in the moment for this brief period of time.
Directions: Find a place to practice mindfulness that is free from intrusions and distractions. Place a clock or other time keeping device where you can monitor the time, or set an alarm to sound when your designated time is complete. You may find it difficult at first, but continue practicing until you can be mindful for 15 minutes. Begin with five minutes and work up to 15 or more minutes.
Sit in silence, either with your eyes open or closed, and become aware of your breathing.
Concentrate on your breathing, and allow it to become deep and even. Stay with this concentration until it seems effortless to breathe deeply and evenly.
Expand your conscious awareness to your body, and note the sensations you are experiencing.
If you have intrusive thoughts, such as concerns or tasks that need to be done, just note these and let them go by returning to concentration on your breathing. Do this as many times as necessary.
It can help to consider the intrusive thoughts as pictures you see on a billboard as you ride past in a car or train. They are there, but then you are past them. Or use any imagery that appeals to you, such as seeing these as clouds in the sky, leaves floating down a stream, birds flying over, and the like.
Sit in this silence until you are ready to come back and stop.
Discussion/Reflection Questions for Mindfulness
Practice being mindful 15 minutes a day for a week, and write a paragraph about your reactions each day. At the next class session, divide into small groups and share reactions.
Divide into small groups and develop a list of strategies that can be used to develop undeveloped narcissism.
Reflect on and share in small groups the steps a group leader can take to reduce self-absorption and increase his/her emotional presence in the group.
Discussion Questions
Provide three or more examples of empathic failures and their impact on the receiver.
Discuss three to five essential points for why self-development is important for psychoeducational group leaders.
Describe your first experience with practicing mindfulness, and your most recent experience.
Chapter 6
Group Leadership Skills
Major Topics
Group level skills
Group level skills development practice
Elements of effective communication
Ineffective communication
Questioning skill development
Introduction
Effective group leadership encompasses using fundamental and basic counseling attributes and skills, plus the addition of skills that are relative to working with individuals and with the group as a whole. A group is a collection of individuals, but it is much more than that, as there is the group entity that also needs attention and an understanding of the information at that level. Group leaders are more effective when they can tune in to both the individual and to the group as a whole. This chapter focuses on the skills and understandings that are needed for individual and for the group as an entity. Covered will be basic and group level leadership skills, the advanced skill of empathic failure repair and description of some facilitative communication skills.
Group Leadership Skills
Basic task and maintenance group leadership skills include attending, reflection, summarizing, active listening and responding, clarifying, and supporting. In addition, the leader needs some group leadership facilitation skills, including linking, blocking, tuning in to process, confronting, and terminating. All of these are important and may be used in other than traditional ways. With practice, these things can become an integral part of the leader’s skill set. These skills are described in the following paragraphs, and suggested strategies for developing them are given in the section titled “Skill Development” later in this chapter.
Attending incorporates preparation to listen, respect for others, and interest in others. These are primarily nonverbal behaviors, such as a slight forward lean, eye contact, orientation of the body toward the speaker, and not allowing distractions. Attending to members when they are speaking makes them feel valued and that you are interested in what they have to say.
Active listening and responding means being able to hear and understand direct and indirect communications and to convey your understanding to the other person. Tuning in to feelings, hearing the metacommunication, and understanding the role of nonverbal behaviors in communication all play important roles in active listening and responding. Self-awareness is important to the extent that you understand your personal issues and how they may affect your listening and responding skills.
Reflection is a useful skill with psychoeducational groups because members do not always say what they mean, and leaders do not always understand what they mean. Reflecting back what was heard allows for correction of misunderstandings and can produce further elaborations.
Clarification is a part of reflection and active listening. This is the skill of understanding what was meant, illuminating intent, clearing up misconceptions and misunderstandings, and providing clearer direction.
Summarizing the key elements of a session helps members tie the many parts of the experience together. Sessions usually begin with objectives. Summaries show how or if the objectives were met, remaining questions or concerns, other emerging issues, and qualitative judgments about the session. So much has transpired that members may have forgotten what they set out to do, and the summary reminds them that they accomplished the objective(s).
Support by the group leader must be done with care. The leader should take care to not rush in to provide support but instead should judge when members need support and when they can be left to work it out on their own. Learning when support will be productive or counterproductive comes with experience.
Group Level Skills
Group level skills include observing, managing and containing personal emotions, facilitating interpersonal feedback, effective use of silence, identifying and repairing empathic failures, linking, blocking, tuning in to process, confronting, and terminating. These skills are complex and complicated, which makes them difficult to define, describe, and develop.
Observing
Group leaders will find it informative to be observant, especially to be able to observe the group as a whole, as well as observing individual members. Having an emotional presence in group sessions will facilitate observation. Learning what to observe and doing so without judging is a skill to be developed. The discussion about observing specific group dynamics is addressed in the chapter on group dynamics, and this discussion will focus on group as a whole observations.
Assuming a group level perspective takes some time and effort to develop, and what is presented in this book is designed to provide you a process for developing that expertise. Group level observation involves acquiring and synthesizing information from members’ verbal and nonverbal behaviors, and the leader’s inner experiencing that can be a reflection of what the group wants, needs, or is resisting. The leader combines information from these three sources, and then analyzes and synthesizes it to understand what the group may not be able to openly express. All of this is done rapidly, in the session, and at that moment. At some point, the group leader can make these unspoken wants, needs, wishes, and the like visible for the group through process commentary. Following are some behaviors and the leader’s inner experiencing that can focus observations. As you read these, try to focus on the information about the group as a whole.
The group’s focus and emphasis.
Where the energy in the group seems to be located, and around what topic.
The group’s feeling tone. The inner experiencing of the group leader can be especially helpful here.
What the group seems to be avoiding, such as conflict, expressing feelings, and so on.
The session’s theme, derived from how members’ topics and underlying subjects can be linked and combined.
Managing and Containing Personal Emotions
Managing and containing personal emotions by the leader not only models this for group members, but also prevents these from being projected and/or negatively impacting the group on a nonconscious level. It is not unusual for group leaders to have some anxiety, especially at the beginning of the group, or to experience other feelings such as anger during group sessions.
However, group members can be vulnerable to catching others’ emotions, especially when their psychological boundary strength is insufficiently developed so as to prevent this from happening. Therefore, it is important that group leaders make conscious efforts to manage and contain their emotions. A process to accomplish this involves the following steps. This process can also be taught to group members.
An awareness and acceptance of personal feelings.
Sufficient self-development to understand if this feeling is personal, or if part or all of it is a strong projection from one or more group members that the leader caught.
To understand that if the feeling is personal arising from the leader’s issues, that it should be explored outside the group and not during the group session.
An understanding that if the feeling is being caught, then using that to better understand what group members are feeling and respond appropriately. For example, if the caught feeling is some variation of fear such as apprehension, group members may be fearful of what can happen in the group, and the group leader can say something like, “It can be scary to not know what will happen in the group.”
The task is for the group leader to refrain from making the group responsible for his/her feelings. Focus on the group and members, don’t focus on or address what you are feeling at that moment unless you are sure that you are probably containing the feelings for the group. If you are functioning as the group’s container, the feelings are then a valuable source of information about the group, and will be used in a different way.
Facilitating Constructive Interpersonal Feedback
Many psychoeducational groups will have members who are strangers to each other, while other groups will be acquainted and/or have other relationships with each other. In either case, the group leader needs to be able to facilitate interpersonal feedback among group members although this will call for different tactics depending on the relationships among group members.
Regardless of the focus and purpose for the group, the leader should be ready and knowledgeable to help members provide constructive feedback to each other. It may be necessary to teach them the characteristics of constructive feedback, that is, a nonjudgmental attitude, respectfulness and awareness of the impact of the feedback on the receiver, to refrain from blame or criticism, focus the feedback on something over which the receiver has control or influence, to not give advice or ask rhetorical questions, and have a genuine and caring frame of mind when providing the feedback. Guidelines for giving and receiving constructive interpersonal feedback are provided at the end of this section.
Facilitating interpersonal feedback also prevents and/or repairs empathic failures, especially when there is no response to a member’s input, or the response is another member’s story, or members start to solve the “problem” or try to “fix” that member, and so on. Develop a personal script for intervening and facilitating feedback, but here is one to provide an example and to get started.
“When (name of person) told us about (the event or topic), no one responded (or whatever happened such as changing the topic). It could be helpful to tell (name) what feelings were triggered for you as you listened to him/her.”
Or, if the members began to tell their own stories, give advice and other such actions, first block to stop the action, and then use the example statement.
Table 6.1 presents guidelines for providing feedback. Table 6.2 presents guidelines for the receiver to help manage negative and/or intense feelings that may be aroused.
Table 6.1 Guidelines for Providing Feedback
• Focus on observable behavior.
• Stay emotionally present, and resist thinking about something else.
• Do not make inferences, such as member’s degree of comfort.
• Become mindful and just observe without judgments.
• Provide feedback that is objective and descriptive of observable behavior, free from evaluation/judgments, personal opinions, inferences, and the like.
• Use a neutral voice tone when providing feedback.
• Carefully select descriptors and other words.
Providing Feedback/Reporting Observations
Become mindful that statements of fact can be heard and interpreted by the receiver as a judgment and/or evaluative even when stated in a neutral voice tone. Receivers can have the following responses.
• The statement can be taken personally as blaming or critical of them.
• It can arouse transference, or associations with other past experiences.
• It can be introjected by the receiver, and defended against.
• It can be responded to defensively, such as rationalized, denied, intellectualized, and/or explained.
Table 6.2 Managing Personal Responses to Feedback
If you experience any of the described responses, such as taking it personally, become mindful of the following:
• You cause your feelings—not the other person.
• You don’t have to “take it personally,” even when that is the speaker’s intent.
• The feelings aroused or that emerge can be explored for the association with past experiences—unconscious introjections you have that are being acted on or acted out.
• You may be reacting to you self-perceptions of thoughts about your adequacy, worthiness, lovability, and so on.
• Try to understand the validity of the perceived to your self.
• Consider the extent to which your undeveloped narcissism (e.g., grandiosity, impoverished self, or excessive self-focus) may be contributing to your distress.
• You may not have accurately heard what was said and meant, and your response may be off target.
Tips for Managing Responses to Feedback
Become or stay aware of your tendencies to assume and/or infer judgments and evaluations.
• Think; consider the possibility that the statement of fact was just that—an observation that can be verified by others—and the speaker was not making judgments or evaluations.
• Explore the aroused feeling now or later by associating your response with your past (e.g., possible transference, and other experiences; and your tendency to jump to conclusions, etc.).
• Assess the threat to your self by what was said. Most likely, there is little or no threat.
• Assume responsibility for your feeling(s).
• Resist the urge to explain, rationalize, analyze, and/or retaliate.
• Use the information provided in the feedback in a constructive (to you) way. You don’t have to agree with it, but it may be worth considering.
Leaders must remain mindful that statements of fact can be heard and interpreted by the receiver as judgments and/or as evaluative even when stated in a neutral voice tone. The message from the feedback may have unintended effects such as the following:
The statement can be taken personally as blame or criticism, or even as an attack.
It can arouse transference, or associations with other past experiences.
It can be taken in by the receiver (introjected), and then defended.
It can trigger defensiveness, such as rationalization, denial, intellectualization, and/or cause an extensive explanation.
When any of these reactions occur, this can be an opportunity to model and teach how to manage responses to feedback, such as what is presented in Table 6.2.
Effective Use of Silence
Silence can be anxiety provoking in the group. Many people are uncomfortable with silence and tend to either rush to fill the silence, or become so anxious and fearful that they cannot or do not speak, or a sensitive personal issue could be touched on if they speak and the silence is a form of resistance. This is not a constructive silence. On the other hand, sometimes silence denotes reflection and thoughtfulness, a need for some space to contemplate and think things through. This is an example of a constructive silence.
Then too, there are times when the group leader has a low toleration for silence, and acts to keep the session active so that he/she does not have to experience the anxiety, tension, fear, and/or general discomfort that silence can produce. An inability to tolerate silence can keep a group leader from effectively using it to help the group and its members. One of the most helpful skills for a leader to develop is a toleration for silence, and an understanding of what the silence means for the group at that particular time. This understanding can lead to effective interventions.
Strategies to use for silence include doing nothing and letting the silence build until a member says something; remark on what the silence feels like to the leader, for example, the silence feels like members are reflecting; or ask what the silence could be about, such as suppressing comments to prevent a possible conflict; or if the silence is resistance, just mentally note it but leave it alone. A skilled group leader can make an educated guess about what may be being suppressed or avoided, and the like, because she/he is emotionally present in the session and tuned in to the group’s process.
Repairing Empathic Failures
This is a group level skill that is very beneficial to the group as well as for individual members who can be empathically failed. While this topic is discussed in more detail elsewhere in the book, it is also presented here as a group level leader skill because it is so important to the group’s functioning, and it is a primary leader responsibility.
Benefits for the group as a whole can be the following:
It becomes evident that the group leader is attuned to the group and is emotionally present.
Members who were not empathically failed can feel reassured that the leader is attending and caring.
There is also reassurance that feelings are important, and even intense and distressing ones can be heard in the group.
Members learn the importance and necessity to respond empathically to strengthen and build relationships.
Feelings and perceptions of safety and trust are enhanced and expanded.
While repair of empathic failure is best done in the session where it occurred, it can still be effective if done in a subsequent session. Leaders, even very alert, caring and skillful leaders, can miss or commit an empathic failure. In this instance, the group leader first acknowledges that he/she missed the failure, and then responds to what was missed.
For example, if a member did not receive a response and his/her feelings were not responded to, the leader would note that he/she did hear those feelings, and then respond to what was missed. For example, suppose that Mary commented about something that was upsetting to her, but no one responded, including the leader. The leader reflected on the group session and identified that an empathic failure occurred. At the next session the leader could say to Mary, “Last session when you commented that you were upset about ______, you did not receive a response. I want you to know that I heard your distress and frustration.”
If there was a change of topic, note that there was a change, and reflect the feelings spoken or alluded to by that member before the topic was changed. This will model empathic failure repair, and other members will begin to notice and help repair or even prevent empathic failures.
Linking
Linking involves relating what members are doing and saying among the group to identify commonalities, similarities, and patterns. This is an advanced skill that comes with practice and experience. The leader has to listen carefully to discern such commonalities and patterns.
Illuminating these for members promotes growth and development for the group and for individual members. The group can become more cohesive and members can relate to each other in meaningful ways to gain interpersonal learning about self.
Leaders can say something similar to the follow for linking. “____ seems similar to another (issue, problem, concern, situation, or event) you described before”; “Your story has some elements similar to what (another group member) told us about (use a core issue or feeling to make the similarity)”; and “Each group member has expressed (their discomfort, or resistance or something else) in a different way [use one of the following or something else: some were silent, some changed the topic, someone told a joke, a member moved the chair back from the group—use observable behaviors).” The underlying theme of the actions become linked.
Blocking
Blocking involves intervening to stop intellectualizing, storytelling, inappropriate responses, or any behavior that negatively affects the progress of the group or the well-being of group members. Blocking must be done so that it cuts off the undesired behavior without blaming or criticizing. Leaders must take care not to make members feel chastised or wrong.
Leaders can block by gently interrupting the speaker and saying something like the following:
“(Name of group member), I want to stop you at this point because:
I’m getting lost in the details of what you are saying, and have lost sight of the core concern.
I’m not getting a clear sense of your feelings about (the person, situation, event).
You want us to understand and see your perspective so you are providing as many details as possible.
I think it would be helpful for me and the group if you can state the concern in six words.
You seem to be telling us about several issues. Which one do you consider to be the most important?”
Tuning in to Process
Tuning in to process involves evaluating the ongoing progress and process of the group, which generally is left to the leader. Most of the other skills discussed here can be manifested by group members, but evaluation requires knowledge of group process generally not held by members unless they have had education or training in it. Understanding the stages of a group and the process taking place in it are skills developed by the experienced group leader.
Confronting
Confronting is a skill that is misunderstood by many people. It has come to be synonymous with attack. The accurate meaning of confrontation, however, does not involve attacking, telling someone off, or force of any kind. Confrontation is an invitation, not an imposition. The receiver is invited to look at an aspect of him or herself and its impact on others. Confrontation is extended tentatively, not forced on the other person. Telling someone what you think he or she needs to know is an attack, not a confrontation. The giver of the confrontation must be clear about his or her personal motives before taking action. Wanting to retaliate, tell someone off, or discount another person are inappropriate reasons for confronting. Chapter 10 provides more information on how to make confrontation constructive.
Terminating
It is important to have constructive terminations for sessions and for the ending of the group. Too many times experiences are simply stopped, not ended in such a way as to provide closure for participants. Group leaders should take the time to decisively end sessions. Constructive termination ensures that loose ends are tied up, important and intense feelings are dealt with so that members are not left dangling, and participants have an opportunity to say goodbye to one another.
Summary
Knowing what is effective and what to avoid is important for group leaders. Many of these skills seem relatively easy to master in isolation. It is much more difficult to use them when so much is happening in the group at every moment. All groups are dynamic, and the effective leader recognizes and accepts that fact and does not attempt to ignore the complexity.
Further, an effective leader is aware of his or her personal needs and uses these in constructive ways to facilitate the group. Group members are valued as worthwhile, unique individuals, not as pawns to be manipulated for their own or for the leader’s good.
Group Level Skill Development Practice
Following are some common group situations. Select the answer closest to the choice you think you would make under the circumstances. There are no right or wrong answers. However, some are more effective than are others. Assume that you are the group leader.
This is the first meeting of a psychoeducational group of young adolescent girls in a high school, and is designed to help them develop relationship skills. You welcome the group members, and explain the purpose of the group and how you intend to facilitate the group. As part of the introduction, you present the session’s agenda, which begins with an icebreaker. However, after the introductory remarks, the members begin to pepper you with questions about what they are supposed to do in the group, what is the group’s purpose, and why are they in the group, all of which you addressed in the introductory remarks. Your action/response is to
Try and answer their questions as best you can.
Move ahead with the planned activity and tell them you’ll answer their questions later.
Ask them for their thoughts about the group.
Tell them that it can be very anxiety producing to face a new and unfamiliar situation.
Ask them if they are anxious and scared, and explore their answers.
This group of young adults has been meeting for several sessions, and you feel that the group is going well. They seem willing to talk about their abuse of alcohol, and to participate in planned activities. This session begins like the other sessions with a check-in about members’ week, and you comment on each. No important or urgent concerns are surfacing, and you start to move on to the planned mini-lecture. As you introduce the mini-lecture, a couple of side conversations appear, a member scoots his chair out of the circle, and another member heaves a big sigh. You start your talk, but the side conversations are disruptive. Your action/response is to
Ask the participants in the side conversations to bring these into the group.
Ask the participants in the side conversations to stop and pay attention.
Do nothing and continue with your mini-lecture.
Stop and ask members what seems to be suppressed (is not being talked about) in the group at that time.
Remind members that they will find it beneficial to pay attention.
The group is a work group in an organization, and the topic is time management. Midway through the second session, a conflict breaks out between two of the members over a work-related issue. Curt, irritated words are exchanged and other group members look uncomfortable. Your action/response is to
Ignore the conflict, as it is not related to the group.
Introduce a new activity.
Call for an unplanned break and talk to the two members about their conflict.
Acknowledge the conflict, and ask if it would be helpful to work on it in the group.
Ask the conflicting members to leave.
Discussion About Intervention Choice
While there can be several effective responses, if the intent is to focus on group level responses, some of the choices can be more effective than others. Following is a short explanation for each choice.
The questions reflect members’ anxiety about the ambiguity and uncertainty surrounding the group and their roles. Answering factual questions will not reduce their anxiety as they were answered in the introduction.
Ignoring their questions is likely to increase anxiety and would not contribute to establishing trust and safety.
Turning it back on group members could be perceived as your inability or unwillingness to meet their needs.
This answer acknowledges their anxiety, which can help reduce it as well as showing that you understand what they are experiencing.
This may be less effective than choice d as it asks a question instead of making an empathic statement. However, it also addresses their unspoken concerns.
This is an intervention that would have the side conversations cease. However, none of the other behaviors are addressed, nor is the group resistance understood.
This response would most likely be perceived as critical and blaming. The group resistance is not addressed.
Ignoring the group resistance is not helpful, as some of the disruptive behaviors are likely to continue during the mini-lecture.
This could be an effective response to address the group resistance, especially if the group leader describes the behaviors that caused the leader’s response.
Chiding group members is seldom or never effective, and provides another situation that would need to be addressed.
The conflict is impacting other group members and it is ineffective to ignore it.
Introducing a new activity is also ignoring the conflict and its impact, but doing so could defuse the situation.
This could be effective for the members in the conflict, but does not address its impact on group members.
This could be effective if you are prepared to model conflict resolution, and they agree to participate. It would also be helpful and necessary to survey group members about their feelings during the conflict and the conflict resolution process. If they say no, refer to answer b.
This response sends an undesirable message to other group members, and shames the members in the conflict.
Elements of Effective Communication
Elements of Effective Communication
Basic communication skills form the foundation for group leadership skills. The leader must be able to attend, paraphrase, and reflect as a part of active listening and responding; question appropriately; and confront in a constructive way. These skills allow the leader to be facilitative and to structure and perform task and relationship functions that help groups progress and be successful. Further, these basic skills are the foundation on which more complex skills are developed. The leader calls on all of the basic skills to link, block, and summarize.
A leader is more effective if he or she uses clear, concise, direct, and open communication. The effective leader takes steps to ensure that he or she understands and is understood. Some characteristics of effective communication are two-way active listening, feedback, lack of listener stress, clarity, and focusing on the core issue.
Two-Way Active Listening
Two-way communication means that ideas, information, opinions, attitudes, and feelings flow between communicators. For psychoeducational groups, the leader and members each contribute to the functioning of the group. While the leader is, or should be, more knowledgeable, members also need to feel competent.
Active listening cannot be overemphasized. Hearing what was said and understanding what was meant are skills an effective leader must develop. Messages involve both feelings and content, but most listening focuses only on content, with little attention to feelings. This is a critical mistake, as the primary part of the message is the feeling part, not the content. Because psychoeducational groups usually are content focused and task oriented, the focus tends to be on those aspects, and feelings often are overlooked or discounted. No matter how important content is, it is important to hear and respond to the metacommunication contained in the nonverbal behavior for understanding the real feelings.
Effective Feedback
Effective feedback has several components: active listening and responding, attention to nonverbal behaviors, recognition of the impact of the feedback on the other person, and the amount and timing of the feedback. Feedback is effective when the receiver can absorb and use it. It is ineffective if the receiver feels overwhelmed or attacked, rejects or resists the feedback, or has an undesirable reaction to it (e.g., withdrawal). As the leader, respond with only the amount of feedback a receiver can tolerate or use, not the amount you wish to give. Specific guidelines are given later in this chapter.
Lack of Stress
Lack of stress refers to communicating without having to worry about being understood. The leader uses vocabulary appropriate for the audience, concepts that are generally understood and jargon-free, and limited amounts of information. Nothing is more disagreeable to group members than to feel the leader is talking down to them. Effective leaders gauge the comprehension level of participants and communicate in terms that promote interactions and understanding. As the leader, you have enough variables to consider without worrying about whether members understand what you mean.
Clarity
It is not possible to have all communication be clear and unambiguous. However, effective communication strives for that ideal. This is particularly important in groups in which considerable activity is taking place and intense feelings are apt to be present. One problem is that everyone tends to hear or understand through a perceptual filter—that is, past experiences, relationships, sense of self, and level of emotionality interact to filter what is heard and understood. In some instances, the perceptual filter distorts what is communicated. You can help by clarifying what was said or meant.
Focus on the Core Issue
Focusing on the core issue is a complex skill that incorporates active listening, linking, summarizing, and understanding issues and the indirect ways they may be communicated. This skill is learned over time. Focusing is enhanced when the leader can screen out irrelevances from the story.
Developing Listening and Responding Skills
Tables 6.3 and 6.4 are designed to help you become aware of your listening habits and communication style. You may find it helpful to record your answers to the scales and to ask someone with whom you interact on a regular basis to rate you as well. The items also provide a list of behaviors you might want to increase, decrease, or eliminate.
Table 6.3 Listening Habits Scale
Listening and Responding Skills
Paraphrasing is restating what has been said, without parroting, in order to give the speaker your understanding of what he or she said. This way, the speaker has an opportunity to clear up any misunderstanding. Paraphrasing refers to content and is a part of reflecting, which includes both content and feelings.
Paraphrasing reduces confusion and misunderstandings that can easily occur. We tend to hear what is said through a perceptual screen influenced by our physical and emotional state as well as by our reaction to the speaker. In addition, there are times when speakers do not say what they intend to say. Paraphrasing allows for early corrections.
Learning to restate what you hear may be difficult and uncomfortable at first. Thinking of what words to use so that the speaker does not hear his or her exact words quoted back takes some practice. Judging when paraphrasing is needed is another skill that must be developed. In order to be effective, paraphrasing must be practiced.
You should use paraphrasing when a speaker is being overly general and you want more specificity. For example, if the speaker says that he or she would make a good counselor, you might paraphrase to see if your perception of a good counselor is the same as his or hers. In this case, you might say something like, “You see yourself as being able to guide others to help themselves?” Another time paraphrasing is helpful is when the speaker’s comments are general and examples should be suggested. For example, if the speaker says “We are not getting qualified students in the program,” you can paraphrase by saying, “Do you mean that too many students are failing, or that the quality of work in your class has decreased, or that test scores are lower than those of a few years ago?”
Situations when paraphrasing is useful include when complex or complicated directions are given, when the speaker has used vague or general terms, when an example provides clarification, and when either the speaker or the receiver has strong emotional involvement. It is not necessary to paraphrase every statement. However, it is a component in active listening.
Table 6.4 Effective Verbal Communication Behaviors
Reflection involves both the content and feelings involved in the message. It has the same purposes as paraphrasing: reducing misunderstandings, promoting clarity, and conveying understanding of meaning to the speaker. The most important thing to remember is that the perceived feelings should be clearly identified and labeled.
Effective reflection involves attending, an openness to experiencing, and an ability to describe or label feelings. Learning a feeling language is an important part of developing reflecting skills. To get started, you can work on expanding your vocabulary with particular attention to words describing mild forms of intense emotions. For example, if a speaker is annoyed and you term the emotion as anger, he or she will probably reject the label and feel that you have misunderstood him or her. Here are some guidelines for reflecting:
Identify the underlying message (usually an emotion) and name the emotion you hear.
Be tentative and paraphrase to check for accuracy.
Be alert to connections or links to other verbalizations.
Ineffective Communication
While it is much more beneficial to emphasize effective communication skills, it can also be helpful to identify and recognize how some communication patterns are ineffective, may need to be reduced or eliminated, or can have unintended consequences. There are some communication behaviors the leader should avoid, including speaking for others or the group as a whole instead of making personal statements, asking inappropriate questions, using clichés, and exhibiting defensiveness. These kinds of communication promote inaccuracy of perceptions, game-playing behavior, hiding of the real self (a kind of deception), and feelings of being manipulated.
Following are some ineffective communication styles that tend to arouse hostile feelings and promote resistance. Some of these styles have positive points, as they can be used for appropriate circumstances. For example, in the military there are times when an authoritative response is called for. However, a psychoeducational group leader has little or no need for any of the styles described here.
Authoritarian Communication
The authoritarian is ineffective because he or she assumes a status differential. The authoritarian gives orders and expects those orders to be followed and becomes impatient if there appears to be any questioning of the “orders,” and this attitude tends to dampen interaction between other group members.
Critical Communication
The criticizer points the finger of blame, criticizes, and moralizes. This style of communication uses oughts and shoulds and tends to arouse guilt feelings in others. The criticizer does not seem pleased with anything or anybody and tends to alienate others by making them feel inadequate no matter what they do.
The Expert
The expert knows all the answers and is not shy about imposing them on others. Experts do not wait to be asked for an opinion but rush in and overwhelm others with their “expertise.” Experts tend to think they know a lot about everything.
The Analyst
The analyst always wants to tell others about their motives and underlying reasons for their feelings and behaviors. The person who tries to analyze is even more dangerous when he or she knows a little about human growth and behavior, especially personality theory. Other group members tend to avoid the analyst because his or her communication style arouses hostile, angry feelings. Analyzing can be of use in a therapy session but is not useful and may be dangerous outside of the therapeutic relationship.
The Optimist
The optimist, while seemingly benign, is a problem communicator. We all like to interact with upbeat, optimistic people. They make us feel good and promote hopefulness. However, the eternal optimist is off-putting, because he or she uses this optimism to avoid seeing or dealing with real problems and seeks to minimize or ignore his or her own and others’ feelings.
The Protector
The protector is especially problematic in a group. People who have difficulty dealing with anxiety-provoking situations and those who are emotionally expressive naturally tend to rush in to soothe, rescue, or protect in some way. The message they send is that others need their help. The truth is that protectors are unable or unwilling to deal with their own feelings of discomfort and seek to minimize others’ feelings in an effort to minimize their own. This style is difficult to deal with, because when their help is rejected, protectors feel hurt and others feel guilty, making for a real catch-22 situation.
The Interrogator
The interrogator puts others in the hot seat because his or her questioning and probing, ostensibly used to get at the facts, makes others uncomfortable. Questions have their role, and this is addressed in the section on “Questioning Skill Development” later in this chapter.
The Magician
The magician is a lot like the eternal optimist. He or she tries to make problems, issues, and concerns disappear by refusing to acknowledge their existence. Whereas the eternal optimist brushes aside concerns by minimizing their impact, the magician tries to make them disappear completely by not thinking or talking about them. When the problem resurfaces, the magician shifts the topic to something less threatening. Others feel put down or discounted when the magician communicates with them.
The Generalizer
The generalizer frequently uses words like always and never. Generalizers tend to categorize and make judgments about all instead of seeing others as individuals or situations as varied. Generalizations are rarely appropriate when talking about people’s behavior.
The Accuser
The accuser arouses hostility in others by calling names, labeling, and putting others on the defensive. Communication is ineffective or ceases completely when people feel attacked or labeled in some way. This kind of accusing communication is designed to put others at a disadvantage and to put the accuser at an advantage.
When you do not use personal statements but instead use terms like we, the group, or all of us you are modeling and encouraging the use of indirect and ineffective communication. It is much more effective for the leader and members to take responsibility for their own communications by making personal statements. There are times when you will point out what the group is doing; this is not speaking for the group.
Questioning Skill Development
Questioning can be used effectively if certain points are used to make a conscious choice on when to question. All too often, questions are used inappropriately, leading to ineffective communication. There are three major uses for questions:
To obtain data and information.
To clarify and avoid misunderstandings.
To pinpoint something in order to take immediate action.
Statements usually are more appropriate in other situations.
The primary rule of thumb for a question is to obtain needed data. The word needed is emphasized, because in most counseling situations, additional data are not needed. For example, a group member may be talking about an argument with a boss. Often, another group member or the leader will ask, “Has this happened before?” or “What kind of person is he?” or “Who else was there?”
This information is not needed. You are dealing with the speaker’s experience and his or her feelings. When I point this out to students in my group counseling classes, the response is generally, “I was trying to understand.” We then explore that objective further to determine how the questioned information aids in understanding. Most of the time, it does not give any further information of use. This questioning serves to keep the focus off the speaker and his or her reactions.
There are times when questions are useful for clarification, of course. Verbalizations may be vague, rambling, ambiguous, or confusing. In these cases, questions can help us focus on the essentials and promote understanding of the message and the intent of the speaker. By asking the speaker if our identification of the point is correct, we help to clarify his or her communication. The group leader needs to develop this skill and use it effectively.
Pinpointing is needed in situations where prompt and precise action should be taken. These usually are crises, such as an accident in which someone has been hurt. Group leaders may never face this purpose for questions.
Benjamin (1987) proposed five types of questions: direct, indirect, open, closed, and double. Direct questions are most easily identified. They are specific and to the point. The group leader uses the direct questions most often—for example, “How did you respond?” or “What did you do?” or “Is the agenda meeting your needs?”
Indirect questions usually can be reframed into statements. Making a question into a statement may involve something as simple as changing the inflection at the end—for example, “You are leaving?” becomes “You are leaving.” In the group, you could say, “There seems to be a lot of tension” instead of “Is there tension in the group?” Indirect questions are usually somewhat rhetorical. The speaker either knows the answer or has an opinion. But instead of saying so directly, he or she puts it in the form of a question—in part so that personal ownership of the answer or opinion does not have to be assumed.
Open questions allow the responder the freedom to decide what information to share. These questions may produce unintended results, be confusing or threatening to the receiver, and open the door to storytelling. Open questions are genuinely seeking information, and the speaker has no preconceived ideas about what information he or she wants but is willing to use what is presented.
Closed questions seek to limit the response to specific information or answers. When specific information is needed, a direct, closed question is appropriate. One difficulty with closed questions is that the answer may not give the questioner the information he or she needs because it is too limited—for example, asking someone if he or she has finished an activity allows only a yes-or-no answer. It does not take into consideration that the person may never have engaged in the activity at all (e.g., the classic “Have you stopped beating your wife?”). Closed questions may have the unintended effect of making the receivers feel you are trying to trick them or that you are not interested in their answer if it has the potential for clashing with your opinion or preconceptions.
Double questions put people in a bind by limiting the choice of answers to one out of two when there may be others available—for example, asking people if they want to eat at X or at Y restaurant limits their choices. There may be dozens of other eating places available and one of these could be more to their liking. Limiting choices can be useful if these are, in fact, the only choices (e.g., asking a child if he or she wants to wear the green shirt or the yellow one when those are the only two that coordinate with the rest of the outfit).
Become aware of how often you ask questions. One helpful exercise is to tally the number of questions you ask in a day. Another exercise is to go an entire weekend without asking questions, except as facts are needed.
The next step is to become aware of the type of question you ask most frequently and to determine how many of your questions are genuine requests for information—for example, when you ask someone, “How are you?” do you really want to know, or is it just your way of being polite? How can the person know if you are really interested or just being polite?
Begin to make a conscious evaluation of the need for asking a question. Can you make a statement instead? What advantage is there in asking a question?
Along with the growth in self-awareness, observe your own behavior and that of others when asking questions. It is not unusual to ask many questions of the same person. In a sense, you bombard the person with questions. This can produce feelings of being attacked, and the resulting behavior is a defense, an attack, or a retreat. None of these behaviors promote effective communication.
There is an art to encouraging members to actively participate, and stimulation of good questions is a good leadership skill. Good questions show interest and relevancy, encourage participation and interaction, and point out the need for elaboration or clarification. The leader, however, cannot count on getting good questions from members, so an additional skill you need to develop is turning inadequate questions into good questions.
Your first task as group leader is to examine your reactions to questions. Some common reactions are to become defensive, see questions as threats to your expertise or leadership, rush in to answer quickly, answer indirectly or with a question, and ignore the question. Responding appropriately to questions involves self-awareness, observation of the questioner, judging the appropriateness of a response, as well as other communication skills. Table 6.5 presents some suggestions for modifying reactions to questions. The subsequent discussion focuses on when it may be appropriate to use some of these reactions.
Table 6.5 Reactions and Modifications to Receiving Questions
Reaction
Modification
Become defensive
Do not take questions personally. Do not explain or apologize unless called for.
Questions perceived as threats
Suppress your anger. Identify why or what about the question is threatening. Do not express the anger, cut the person off, or discount him or her in any way.
Answering quickly
Mentally count 5 seconds. This gives you time to make sure you understand the question. Use clarification before answering.
Answering indirectly
Increase consciousness of answering indirectly and make a conscious effort to give direct answers. Indirect answers leave people confused and frustrated.
Answering with a question
If you are not sure you understand, this may be appropriate. If, however, you do this under other circumstances, ask yourself what you are seeking to do. Some motives are to make the other person feel inept, to show off, or to change the topic. Reduce this behavior.
Ignoring the question
This is very similar to answering indirectly but does not show as much respect. You may not wish to answer the question and should directly say so.
There are few rules or guidelines that are appropriate for all situations. The same is true for how to field questions from members. Becoming defensive or perceiving questions as threats speaks to characteristics more than skills. These reactions are unique to the individual and usually have their antecedents in past personal experiences. Some of the other reactions may be appropriate under unique or differing circumstances.
Answering quickly may be useful for blocking undesired or inappropriate behavior. It may relieve tension and provide members with a sense of security. Indirect answers can be useful if some members lack the verbal facility or the confidence to ask direct questions. What they ask is not what they want to know, and the leader is aware of this. An indirect answer addresses the real question, and thus it can be more rewarding to the questioner than a direct answer.
Ignoring a question is tricky. You run the risk of alienating the speaker by having no response. But there are a few circumstances where it may be more helpful to act as if the question had not been asked—for example, when the question is rhetorical, when it is asked and answered almost at once, and when basically the same question is asked by several members at the same time. Rather than ignoring questions, you could refocus, reframe, or explore implications.
Once you have worked through your awareness of questioning behavior and reactions, it becomes easier to field questions from members. A larger concern then becomes how to encourage and stimulate questions. Some suggestions are presented here:
Determine your expectations. How do you want questions to be asked? Only when you give space for and request them? At any time? How do you want participants to ask questions—by raising their hands and being recognized or by jumping in? This is your group and you call the shots.
Inform group members of your expectations. Don’t expect members to read your mind and know your expectations. If you are giving a mini lecture during which questions will be a distraction, ask that questions be held until the end. If you do not mind being interrupted, say so.
Ask if members have any questions and pause a few seconds before continuing. There are some points at which a leader should open the floor to questions—for example, after reviewing the objectives and schedule, after giving directions for an exercise or activity, after disseminating information (e.g., a mini-lecture), and after a discussion.
Do not ask for questions just before a break. Questions and answers have a way of generating discussions. Sticking to the agreed-upon schedule is important, and these discussions can easily run over the time period. If one or two members have burning questions, you can remain a few minutes after group to answer them.
Inappropriate Questions
Inappropriate questions fall into several categories: limiting, putting someone on the spot, hypothetical, demands, reflected, rhetorical, and trapping. These are all ineffective ways of communicating. Questions should be limited to asking for needed information; they are not to communicate a position or a point.
Limiting questions seek to contain or narrow the range of responses. The questioner is trying to obtain a particular response and asks questions in such a way that the desired answer is the most likely one or the only one that can be given. Examples of limiting questions are “Don’t you think that…?” or “Wouldn’t you rather…?”
It is relatively easy to put someone on the spot with questions. The purpose is to punish the speaker rather than to obtain needed information. Leading the speaker with questions is a form of manipulation. Some individuals think that if they ask a series of questions, the other person will come to a desired conclusion. It is a kind of herding or locking in, to get your own point across in an indirect way. It is much more effective to simply state your opinion or position, however, rather than to ask unnecessary questions designed to put someone on the spot.
Hypothetical questions are seldom used to elicit new information. If used to present a possible scenario in order to see how the other person would respond, a hypothetical question is useful and legitimate. Most often, however, the hypothetical question is used to probe for an answer to a question the speaker is afraid to ask directly.
Questions such as “When are you going to…?” are implied demands. The questioner is not really interested in gaining new information; the question is a goad or a command to do something. Some people are reluctant to state what they want. They disguise this with questions about what the other person’s wants or preferences are. There are times when both parties wind up doing something neither wants because of indirect communication through questions.
Rhetorical questions usually are followed by a phrase that assumes approval in advance (e.g., “Right?” “Okay?”). Such statements or requests also may be preceded with “Don’t you think that…?” or “Isn’t it true that…?” Rhetorical questions are framed in such a way that the desired response is ensured not to elicit new information or opinions.
Some people have developed the habit of asking questions instead of making statements. Group leaders need to become aware of their communication behavior and take steps to limit questions to requests for information.
Discussion/Reflection Questions
Discuss in small groups your answers to the Group Level Skills Development Practice activity. Describe how and why you selected the responses you chose.
Describe three to five actions you can take to increase your listening skills. Share these in small groups.
List your effective verbal skills, and three to five ineffective verbal behaviors you could change. Share these lists in a small group.
Yalom: Chapters 4 – 6
Chapter 4
The Therapeutic Factors
An Integration
THE THERAPEUTIC FACTORS DESCRIBED IN THE PREVIOUS chapters can help us formulate a set of effective strategies for the therapist. We know group therapy works, but we want to address more fully how it works. We want to look “under the hood” to the processes by which group therapy exerts its effects. While we believe that the compendium of therapeutic factors we have presented is comprehensive, it is not yet fully applicable clinically. That’s because, for the sake of clarity, we have considered these therapeutic factors as separate entities, whereas in fact they are intricately interdependent. We believe that group leaders are more effective when they are able to harness the interplay of these therapeutic factors.
In this chapter we first consider how the therapeutic factors operate when they are viewed not separately but as part of a dynamic process. Next, we address the comparative potency of the therapeutic factors. Obviously, they are not all of equal value at all times. However, an absolute rank-ordering of therapeutic factors is not possible across all therapeutic groups. Many variables must be considered. The importance of various therapeutic factors depends on the type of group therapy practiced. Groups differ in their clinical populations, therapeutic goals, and treatment settings—for example, whether they are eating disorder groups, panic disorder groups, substance abuse groups, medical illness groups, online groups, outpatient groups, brief therapy groups, inpatient groups, partial hospitalization groups, or peer support groups. College counseling centers may offer ten or twenty different group therapies with a variety of foci, including LGBTQ concerns, mood and anxiety management, eating disorders, substance abuse, sexual assault, dating, writing blocks, and social justice, anti-racism, and anti-oppression issues.1 Each of these groups will likely emphasize different clusters of therapeutic factors; moreover, even a single group may change over time, with some therapeutic factors taking precedence at one stage of a group and others predominating at other stages.
Some factors arise naturally in groups and others emerge only through specific therapist intent and skill. WithinWithin the same group or even the same session, different clients benefit from different therapeutic factors. Group members will respond to different factors depending on their needs, their attachment models, their social skills, and their character structure.2 Each group member’s use of a therapeutic factor can impact how others in the group experience the group therapeutic factors: one member’s self-disclosure can foster a feeling of universality in another member, or generate altruism in yet another. We must also recognize that we are discussing therapeutic factors from a Western perspective on psychotherapy: other cultures may prioritize the therapeutic factors differently.
Some factors are not always independent forces but instead create conditions for change. Instillation of hope, for example, may serve largely to prevent early discouragement and to keep members in the group until other forces for change come into play. Or consider cohesiveness: for some members, the sheer experience of being an accepted, valued member of a group may in itself be the major mechanism of change. Yet for others, cohesiveness is important, because it provides the conditions of the safety and support that allow them to express emotion, request feedback, and experiment with new interpersonal behavior.
Our efforts to evaluate and integrate the therapeutic factors will always remain, to some extent, conjectural. Over the past forty-five years there has been a groundswell of research on the therapeutic factors; recent reviews have cited hundreds of studies.3 In efforts to increase the clinical utility of the therapeutic factors, some researchers categorize which groupings of therapeutic factors may be of greatest importance to particular types of groups. All of these formulations are predicated upon the factors described in this chapter.4 Yet there has been limited definitive research on the comparative value of the therapeutic factors and how they interrelate; indeed, we may never attain a high degree of certainty about these comparative values.
We do not speak from a position of investigative nihilism but instead argue that our data on therapeutic factors is so highly subjective that it challenges scientific methodology. No matter how we try to improve our data collection, we are still left trying to quantify and categorize subjective dimensions that do not fit easily into an objective categorical system.5 Accepting these research limitations, we must also recognize that there is great value in understanding the client experience through the lens of these therapeutic elements. Consider the following not atypical clinical illustration, which demonstrates the difficulty of determining which factor is most therapeutic within a treatment experience:
> A new member, Barbara, a thirty-six-year-old chronically depressed single woman, sobbed as she told the group that she had been laid off. Although her job had paid little and she disliked the work, she viewed the layoff as evidence that she was unacceptable and doomed to a miserable, unhappy life. Other group members offered support and reassurance, but with minimal apparent impact. Another member, Gail, who was fifty years old and herself no stranger to depression, urged Barbara to stop beating herself up, and added that it was only after a year of hard work in the group that she was able to attain a stable mood and to view negative events as disappointments rather than damning personal indictments.
Barbara nodded and then told the group that she had desperately needed to talk and had arrived early for the meeting. However, seeing no one else in the group room, she assumed not only that the group had been canceled but also that the leader had neglected to notify her. She was angry and contemplating leaving when the group members began to arrive. As she talked, she smiled knowingly, recognizing the depressive assumptions she continually made.
After a short reflection, she recalled a memory of her childhood—of her anxious mother, and her family’s motto, “Disaster is always around the corner.” She recalled that at age eight she’d had a diagnostic workup for tuberculosis because of a questionable skin test. Her mother had said, “Don’t worry—I will visit you at the sanitarium.” The diagnostic workup was negative, but her mother’s echoing words still filled her with dread. Barbara then added, “I can’t tell you what it’s like for me today, in this group, to receive this kind of feedback and reassurance instead.” << We can see in this brief illustration the presence of several therapeutic factors—universality, instillation of hope, self-understanding, imparting of information, family reenactment (corrective recapitulation of the primary family group), interpersonal learning, and catharsis. Which therapeutic factor is primary? How can we determine that with any certainty? The study of insight in group therapy illustrates this complexity. Four studies attempted to quantify and evaluate insight by comparing insight groups with such groups as assertiveness training groups or interactional here-and-now groups (as though such interactional groups offered no insight).6 The researchers measured insight by counting the therapist’s insight-providing comments. Such a design, however, fails to take into account crucial aspects of the experience of insight: for example, how accurate was the therapist’s comment? How well timed? The client’s state of readiness to accept it? The nature of the client’s relationship with the therapist? (If adversarial, the client is apt to reject any interpretation; if dependent, the client may ingest all interpretations without discrimination.) Insight is a deeply subjective experience that cannot be easily rated by objective measures (one accurate, well-timed interpretation is worth a score of interpretations that fail to hit home). Keep in mind that empathic and accurate interpretations, delivered without blaming or shaming, do contribute to better and more durable clinical psychotherapy outcomes, particularly for clients whose few and limited relationships have been generally disappointing.7 In virtually every form of psychotherapy, the therapist must appreciate the full context of the client’s experience to understand the nature of effective therapeutic interventions.8 As a result, we fear that empirical psychotherapy research may never provide the certainty we crave, and we must learn to live effectively with uncertainty. We must listen to what clients tell us and consider the best available evidence from research and intelligent clinical observation. Ultimately, we must evolve a reasoned therapy that offers the great flexibility needed to cope with the infinite range of human problems. COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: THE CLIENT’S VIEW How do group members evaluate the various therapeutic factors? Which factors do they regard as most salient to their improvement in therapy? In the first two editions of this book, it was possible to take a leisurely approach to reviewing the small body of research bearing on this question. Only two studies had explicitly explored clients’ subjective appraisals of the therapeutic factors, and I (IY) discussed these and then gave a detailed description of the results of my first therapeutic factor research project. My colleagues and I had administered a therapeutic factor questionnaire to twenty successful group therapy participants. It was designed to provide some data for us to use in comparing the relative importance of the eleven therapeutic factors identified in Chapter 1.9 But things have changed. Over the past five decades, a deluge of studies have explored how clients and therapists view the therapeutic factors. This research has demonstrated that focusing on therapeutic factors offers a useful way for therapists to shape their group therapeutic strategies to match their clients’ goals.10 Most of the researchers have used some version or modification of the therapeutic factors and the research instrument I described in my original 1970 research.11 Therefore, we will describe that research in detail and then incorporate into our discussion the findings from more recent research on therapeutic factors.12 My colleagues and I studied the therapeutic factors in twenty successful long-term group therapy clients.13 We gathered this cohort by asking twenty group therapists to select their most successful client for us to evaluate. These therapists led groups of outpatients who sought care for neurotic or characterological problems. The subjects had been in therapy for between eight and twenty-two months (the mean duration was sixteen months) and had recently terminated or were about to terminate group therapy.14 All subjects completed a therapeutic factor questionnaire in the form of a Q-sort and were interviewed by the investigators. Twelve categories of therapeutic factors were constructed from the sources outlined throughout this book, and five items describing each category were written, making a total of sixty items (see Table 4.1).i These twelve factors, with some changes in nomenclature, eventually evolved into the eleven therapeutic factors we described in Chapter 1. Every item has potential healing impact. Each item was typed on a 3 × 5 card, and then each client was given the stack of randomly arranged cards and asked to place a specified number of cards into seven piles labeled as follows: Most helpful to me in the group (2 cards) Extremely helpful (6 cards) Very helpful (12 cards) Helpful (20 cards) Barely helpful (12 cards) Less helpful (6 cards) Least helpful to me in the group (2 cards)15 TABLE 4.1 Therapeutic Factors: Categories and Rankings of the Sixty Individual Items After this Q-sort, which took thirty to forty-five minutes, each subject was interviewed for an hour by the three investigators. Their reasons for their choice of the most and least helpful items were reviewed, and other areas relevant to therapeutic factors were discussed (for example, other, nonprofessional therapeutic influences in the clients’ lives, critical events in therapy, goal changes, timing of improvement, and therapeutic factors in their own words). Results A sixty-item, seven-pile Q-sort for twenty subjects makes for complex data. Perhaps the clearest way to consider the results is a simple rank-ordering of the sixty items (arrived at by ranking the sum of the twenty pile placements for each item). In Table 4.1, the number after each item represents its rank order. Thus, on average, item 48 (Discovering and accepting previously unknown or unacceptable parts of myself) was considered the most important therapeutic factor by the subjects; item 40 (Finding someone in the group I could pattern myself after) the least important, and so on. The ten items the subjects deemed most helpful were, in order of importance, as follows: 1. Discovering and accepting previously unknown or unacceptable parts of myself. 2. Being able to say what was bothering me instead of holding it in. 3. Other members honestly telling me what they think of me. 4. Learning how to express my feelings. 5. The group teaching me about the type of impression I make on others. 6. Expressing negative and/or positive feelings toward another member. 7. Learning that I must take ultimate responsibility for the way I live my life no matter how much guidance and support I get from others. 8. Learning how I come across to others. 9. Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same. 10. Feeling more trustful of groups and of other people. Note that seven of the first eight items represent some form of catharsis or of insight. We again use insight in the broadest sense; the items, for the most part, reflect the first level of insight described in Chapter 2 (Gaining an objective perspective of one’s interpersonal behavior). This remarkable finding lends considerable weight to the principle, also described in Chapter 2, that therapy is a dual process consisting of emotional experience and reflection on that experience. More, much more, about this later. The administration and scoring of a sixty-item Q-sort is so laborious that most researchers have since used an abbreviated version—generally, one that asks a subject to rank the twelve therapeutic factor categories rather than sixty individual items. However, four studies that replicate the sixty-item Q-sort study reported remarkably similar findings.16 If we analyze the twelve general categories,iii we find the following rank order of importance: 1. Interpersonal—input (learning how I impact others) 2. Catharsis 3. Cohesiveness 4. Self-understanding 5. Interpersonal—output (learning to change how I interact) 6. Existential factors 7. Universality 8. Instillation of hope 9. Altruism 10. Family reenactment 11. Guidance 12. Identification A number of other replicating studies are in considerable agreement.17 The most commonly chosen therapeutic factors are catharsis, self-understanding, and interpersonal—input, closely followed by cohesiveness and universality. The same trio of most helpful therapeutic factors (interpersonal—input, self-understanding, and catharsis) has been reported in studies of personal growth groups.18 One researcher has suggested that the therapeutic factors fall into three main clusters: the remoralization factor (hope, universality, and acceptance), the self-revelation factor (self-disclosure and catharsis), and the specific psychological work factor (interpersonal learning and self-understanding).19 This clustering resembles a factor analysisix of therapeutic factors collected from studies of the American Group Psychotherapy Association Institute’s experiential groups suggesting that the group therapeutic factors fall into three main categories: early factors of belonging and remoralization common to all therapy groups, factors of guidance and instruction, and specific skill-development factors. Another empirical study clustered the therapeutic factors reported by five hundred group clients into two overarching dimensions: the group’s emotional and relationship climate and psychological work.20 Despite different terminology, contemporary clustering approaches suggest that the group therapeutic factors consist of universal mechanisms, mediating mechanisms, and specific change mechanisms. Which therapeutic factors are least valued? All the studies of therapy groups and personal growth groups report the same results: family reenactment, guidance, and identification. These results all suggest that the defining core of the therapeutic process in these therapy groups is an affectively charged, self-reflective, interpersonal interaction in a supportive and trusting setting.22 This is true as well in individual psychotherapy. Comparisons of therapeutic factors in individual and group therapy consistently underscore this finding and the importance of the basic concepts discussed in Chapter 2—the concept of the corrective emotional experience and the concept of the therapeutic here-and-now focus, which includes both the process of deep experiencing and a subsequent process where the client makes sense of that experience and derives meaning from it.23 If our objective is to create the best possible climate for support, self-exploration, and interpersonal learning, then group leaders must understand each of the individual factors and how they relate to one another. All are in play virtually at every moment. An effective group therapist is like an expert chef who appreciates the contribution made by each ingredient to the meal as a whole. The following vignette illustrates these principles: > The session began with the members welcoming Meena back from a two-week trip to India, where she had been born. Meena replied she had a lot to share about her trip but first had to ask about Samantha, who at the last meeting she’d attended was struggling with a huge decision about changing her career and returning to university to finish her pre-med studies.
Samantha raised both hands and said, “I did it—I’m going to be a doctor,” and she and Meena exchanged high fives.
Meena commented, “Samantha, you give me inspiration. I admire your courage to go after what you want and need in life. And I’m going to follow your lead and today say some things I’ve never uttered to anyone before.”
Meena went on to explain that she had always feared others’ judgment, and that her anticipation of shame had silenced her. “I feel like I’ve been caught between a rock and a hard place. In America I feel foreign and ‘the other’ because I am a woman of color, and when I’m in India, I feel foreign and ‘other’ because everyone views me as a westernized American woman. This tension has always caused me to avoid romantic engagement—until now. I see others like Samantha stand up for themselves and go after what they really want. I’m inspired by her.” Meena hesitated, took a deep breath, and continued, “I’m nervous about saying this because in India we were prohibited from seeing or dating men from certain castes. It would not be an issue in the West but at home it was shameful.”
“Yes… and?” asked Samantha.
Meena gulped and took the plunge. “I’m in love with a former classmate who loves me back,” she said. “But I’ve always rebuffed him because of what people there would say. This group has encouraged me to pay attention to my own desires and I’ve now decided to follow my heart. I know now that life is short and should not be squandered because of what I fear others think.”
“Such good news. So, you’ve told him?” asked Samantha.
“Not yet, I wanted first to talk about this here in the group.”
A chorus of encouragement emanated from the group. “Go for it, Meena.” “Yes, follow your heart.” “No risk, no gain.” “I love to see you taking charge of your life. Good for you.”
All her fears about being criticized if she opened up to the group were disconfirmed and Meena exhaled loudly, signaling enormous relief. She said, “A huge weight has been lifted off me tonight. I just hope it’s not too late and he is still there for me.”
Then another member of the group, Bella, an immigrant from Albania, talked about her multicultural experience. The cultural divergence she experienced was much less than the one Meena had experienced, but she recognized there were aspects of child rearing in her former country that were unacceptable here. It was evident that Bella introduced this subject as a way of joining with Meena and letting her see that she was not alone in negotiating cross-cultural tensions.
Bella went on to say that it was time to talk about the real reason she joined the group—her brutal self-judgment. She recounted an episode with her husband three days earlier in which she misheard a comment he made to her. Her husband was not feeling well, and when she asked him to do something, he grew angry and said, “Get off my back!” She heard instead “Get out of my life,” and immediately was flooded with self-loathing. She left her house and retreated to her old bed in her mother’s home only a few blocks away. During the group session, as she was just emerging from this episode, she resolved that it was time to take the bull by the horns and work on her catastrophic reaction to criticism. “The same kind of thing happened to me recently in group, but it involved Mark, who’s absent today, and I don’t know if I should say it.”
The group therapist encouraged Bella to continue, making clear that the group ground rules were that a member could talk about anything, including something that concerned another member, even in that person’s absence, with the proviso that we would revisit the subject in that person’s presence at the next opportunity.
Bella hesitantly continued: “It was that meeting when Mark criticized me for not being compassionate or supportive to him. I’ve brooded about that for weeks but kept it to myself until today. I’m beginning to understand what I need to work on: I am supersensitive, and it is crippling me in life.… I don’t know how I got to be this way, but I think it goes back to my father—he was always on my case. I can still hear him saying, “If you can’t do it right, don’t do it at all.”
Another member, Rick, said, “I liked the way you showed compassion to Meena just now. I wish you’d start to be more compassionate with yourself. And I do hope you’re giving yourself credit for bringing up Mark’s criticism of you—that was gutsy.”
Meena then said to Bella, “I’m still thinking about what you said about your father and the impact of what he said to you. Makes me wonder what is at the heart of getting better here in therapy. What’s most important? Knowing the roots of your difficulty, or understanding things that are impacting right now on your life?”
The group members’ response was unanimous: “What matters is any knowledge that allows you to change in the present.”
Rick commented further, “I’ve been in and out of therapy for many years and although understanding my early life has enriched me in some ways, it was really only in the group that I began to change how I relate to people. Insight without change in fact can make you feel worse, more hopeless and more helpless. It’s not just insight that’s important: it’s insight that leads to change.” << Let’s examine the interplay of the therapeutic factors in this session: • Meena applauds Samantha’s courage in resetting her life course (instillation of hope and vicarious learning) and gains trust in the group’s nonjudgmental support (group cohesion). • Meena internalizes Samantha and the group. Keeping the group alive in her thinking encourages her to try new behaviors. She trusts the group and is eager to dive into work (group cohesion). A sense of security and connection helps Meena to stay with her strong emotions and express her feelings. • Meena takes responsibility for the impact of her earlier rejection of the man she loves and determines that she will now act and take responsibility for her choice (existential factors). This encourages Meena to take a risk in the here-and-now, and she reveals her feelings of shame and explores intertwining psychological and cultural factors (catharsis, self-disclosure, and self-understanding). • Meena is endorsed for her courage and obtains group support rather than the judgment she dreaded (interpersonal learning). Bella’s self-disclosure emerges from her wish to support and join Meena compassionately (altruism, universality) and her recognition that her harsh self-judgment is at the core of her own difficulties (self-understanding). • Bella also tries a new behavior in the group. In response to being criticized in the group by Mark, she comes prepared to explore and examine what happened; this is a constructive departure from her former tendency to withdraw and shut down when someone finds fault with her (interpersonal learning). • The group addresses the importance of insight and concludes that the most critical knowledge acquired in therapy is that which that leads to behavioral change (guidance and self-understanding). In the following sections, we will explore the questions posed at the beginning of this chapter on the interrelationships and comparative potency of the therapeutic factors. Keep in mind that these findings pertain to a specific type of therapy group: an interactionally based group with the ambitious goals of symptom relief and behavioral and characterological change. Later in this chapter we will present some evidence that other groups with different goals and of shorter duration may capitalize on different clusters of therapeutic factors. Catharsis Catharsis has always assumed an important role in the healing process. For centuries, sufferers have been purged to eliminate excessive bile, evil spirits, and infectious toxins. (The word catharsis is derived from the Greek “to clean”). But dynamic psychotherapists have learned that catharsis is not enough. After all, we have emotional discharges, sometimes very intense ones, all our lives that do not lead to change. The data support this conclusion. Although clients consider catharsis important, the research notes important qualifications. My (IY) study on encounter groups with Morton Lieberman and Matthew Miles starkly illustrates the limitations of catharsis per se.24 We asked 210 clients to describe the most significant incident that occurred in the course of their group therapy, a thirty-hour encounter-group experience they had all been part of at different times in previous years. The group members frequently cited experiencing and expressing feelings (both positive and negative). Yet for most of the subjects, this critical incident was unrelated to positive outcome: incidents of catharsis were just as likely to be selected by members with poor outcomes as by those with good outcomes. Catharsis was necessary but not sufficient for change. Indeed, members who cited only catharsis were somewhat more likely to have had a negative experience in the group. The high learners characteristically experienced catharsis plus some form of cognitive learning: the ability to reflect on one’s emotional experience in the context of a caring relationship is what drives change.25 In the Q-sort therapeutic factor studies, the two items that are ranked most highly and are most characteristic of the catharsis category in factor analytic studies are items 34 (Learning how to express my feelings) and 35 (Being able to say what was bothering me). Both of these items convey something other than the sheer act of ventilation or abreaction. They connote a sense of liberation and acquiring skills for the future. The other frequently chosen catharsis item—item 32 (Expressing negative and/or positive feelings toward another member)—indicates the role of catharsis in the ongoing interpersonal process. Note that item 31, which most conveys the purest sense of sheer ventilation (Getting things off my chest), was not highly ranked by group members. Interviews with clients to investigate the reasons for their selection of items confirmed this view. Catharsis was viewed as part of an interpersonal process: no one ever obtains enduring benefit from ventilating feelings in an empty closet. Furthermore, as we discussed in Chapter 3, catharsis is intricately related to cohesiveness. Catharsis is more helpful once supportive group bonds have formed; it is more valued late rather than early in the course of the group.26 In fact, clinical practice guidelines caution that group cohesion may be damaged by the premature expression of strong affect before a sense of safety is established.27 In a research trial with women who had advanced breast cancer, talking about death and dying was a critically important therapeutic objective, but only after the group had consolidated.28 Strong timely expression of emotion enhances the development of cohesiveness: members who express strong feelings toward one another and work honestly with these feelings will develop close mutual bonds. In groups of clients dealing with loss, researchers found that expression of positive affect was associated with positive outcomes, whereas the expression of negative affect was therapeutic only when paired with genuine attempts to understand oneself or other group members.29 Emotional disclosure is also linked to the ability to cope; articulation of one’s needs permits oneself and the people in one’s environment to respond productively to life’s challenges. Women with early-stage breast cancer who are emotionally expressive achieve a much better quality of life than those who avoid and suppress their distress.30 Women with late-stage breast cancer who avoided expressing affect experienced adverse impacts on their blood pressure, signaling autonomic nervous system overload; conversely, appropriate expression of hostility contributed to better autonomic nervous system regulation and better social connectedness.31 Recently bereaved HIV-positive men who are able to express emotions, grieve, and find meaning in their losses maintain significantly higher immune function and live longer than those who minimize their distress and avoid the mourning process.32 In summary, then, the timely, open expression of affect is vital to the group therapeutic process; in its absence, a group would degenerate into a sterile academic exercise. Yet it is only part of the process and must be complemented by other factors. One last point: the intensity of emotional expression is highly relative and must be appreciated not from the leader’s perspective but from that of each member’s subjective world. A seemingly muted expression of emotion may, for a highly constricted individual, represent an event of considerable intensity. Self-Understanding The therapeutic factor Q-sort also underscores the important role that the intellectual components play in the therapeutic process. Of the twelve categories, the two pertaining to the intellectual task in therapy (interpersonal input and self-understanding) are both ranked highly. Interpersonal learning, discussed at some length in Chapter 2, encompasses the process by which the individual learns how he or she is perceived by other people. It is the crucial first step in the sequence of the therapeutic factor of interpersonal learning. The category of self-understanding is more problematic. It was constructed to permit investigation of the importance of derepression and to foster understanding of the relationship between past and present: that is, to spark insight about the early roots of one’s difficulties (sometimes called “genetic insight”). Looking at the five items under the “self-understanding” category in Table 4.1 (46–50), however, one sees that the category is an inconsistent one. It contains several very different elements, and there is poor correlation among the items, some being highly valued by group therapy members and some less so. Item 48, Discovering and accepting previously unknown or unacceptable parts of myself, is the single most valued item of the sixty. Two items (46 and 47), referring to understanding the causes of one’s problems and to recognizing the existence of interpersonal distortion, are also highly valued. The item that most explicitly refers to insight about one’s early life, item 50, is considered of little value by group therapy clients. This finding has been corroborated regularly by other researchers.33 A number of studies, for example, concluded that interpretations about one’s early life were significantly less effective than here-and-now interpersonal feedback in producing positive group therapy outcomes. When making links to the past, co-members’ feedback contained less jargon and was connected more directly to actual experience than were the therapists’ more conceptual, less “real” explanations.34 When we interviewed the subjects in our study, we found that the most popular item—48, Discovering and accepting previously unknown or unacceptable parts of myself—had a very specific implication to group members. More often than not, they discovered positive areas of themselves: the ability to care for another, to relate closely to others, to experience compassion. There is an important lesson to be learned here. Too often, psychotherapy, especially in naive, popularized, or early conceptualizations, is viewed as a detective search, as a digging or a stripping away. But excavation may uncover our riches and treasures as well as the shameful, fearful, or primitive aspects of ourselves.35 Our clients want to be liberated from pathogenic beliefs, and, as they gain fuller access to themselves, they become emboldened and take ownership of their personhood. Psychotherapy has grown beyond its emphasis on eradicating the “pathological” and now aims at increasing clients’ breadth of positive emotions, cognitions, and access to strengths. A group therapy approach that encourages members to create and inhabit a powerful and caring environment is a potent approach to these contemporary goals. Thus, one way that self-understanding promotes change is by encouraging individuals to recognize, integrate, and then give free expression to previously obscured parts of themselves. When we deny or stifle parts of ourselves, we pay a heavy price: we feel a deep, puzzling, amorphous sense of restriction. When we are able to reclaim these disavowed parts, we experience a wholeness and sense of liberation. So far, so good. But what of the other components of the intellectual task? For example, how does the highly ranked item Learning why I think and feel the way I do (item 47) result in therapeutic change? First, we must recognize that there is an urgent need for intellectual understanding in the psychotherapeutic enterprise, a need that comes from both client and therapist. Our search for understanding is deeply rooted. Abraham Maslow, in a treatise on motivation, suggested that the human being has cognitive needs that are as basic as the needs for safety, love, and self-esteem.37 In an analogous fashion, our clients automatically search for understanding, and therapists who prize the intellectual pursuit join them. Often, it all seems so natural that we lose sight of the raison d’être of therapy. After all, the object of therapy is change, not self-understanding. Or is it? Are the two synonymous? Does any and every type of self-understanding lead automatically to change? Or is the quest for self-understanding simply an interesting, appealing, reasonable exercise for clients and therapists, serving, like mortar, to keep the two joined together while something else—“relationship”—develops? Perhaps it is relationship that is the real mutative force in therapy. In fact, there is considerable evidence that a supportive psychotherapy relationship in a noninterpretive therapy can produce substantial change in interpersonal behavior.38 It is far easier to pose these questions than to answer them. We will present some preliminary points here, and in Chapter 6, after developing some material on the interpretative task and techniques of the therapist, we will attempt to present a coherent thesis. If we examine the motives behind our curiosity and our proclivity to explore our environment, we shed some light on the process of change. These motives include effectance (our desire for mastery and power), safety (our desire to render the unexplained harmless through understanding), and pure cognizance (our desire for knowledge and exploration for its own sake).39 The babysitter who explores a mysterious and frightening noise in the house; the senior citizen who discovers the power of the Internet to increase her access to and mobility in the world; the refugee who explores his new and peaceful home environment; the medieval alchemist or the New World explorer probing uncharted and proscribed regions—all receive their respective rewards: safety, a sense of personal keenness and satisfaction, and mastery in the guise of knowledge and self-efficacy.40 Of these motives, the one least relevant for the change process is pure cognizance. But the desires for safety and for mastery play an important and obvious role in psychotherapy. They are, of course, as Robert White has ably discussed, closely intertwined.41 The unexplained—especially the frightening unexplained—cannot be tolerated for long. One of our chief methods of control is through language. Giving a name to chaotic, unruly forces provides us with a sense of mastery or control. In the psychotherapeutic situation, information decreases anxiety by removing ambiguity. There is considerable research evidence supporting this observation.42 If one can name it, one can tame it. We engage the thinking prefrontal cortex to soothe the more emotional, limbic parts of the brain and then plan a course of constructive action.43 The converse is, incidentally, also true: anxiety increases ambiguity by distorting perceptual acuteness. Anxious subjects show disturbed organization of visual perception; they are less capable of perceiving and organizing rapid visual cues than nonanxious subjects and distinctly slower in completing and recognizing incomplete pictures in a controlled experimental setting.44 If we are unable to order the world cognitively, we experience anxiety, which, if severe, interferes with the perceptual apparatus. Thus, anxiety begets anxiety, a sequence that is countered by the two-step process of psychotherapy for highly stressed, emotionally overwhelmed clients. First, the relational experience provides calming and containment to reduce emotional arousal to more workable levels, at which point the therapist can then begin to help the client make sense of powerful experience.45 In psychotherapy, clients are enormously reassured by the belief that their chaotic inner world, their suffering, and their tortuous interpersonal relationships are all explicable and thereby governable. Presumably it follows that if we know what is ultimately good for us, we will act in our own best interests. Therapists, too, are less anxious if, when confronted with great suffering and voluminous, chaotic material, they can believe in a set of principles that will permit an ordered explanation. Frequently, therapists will cling tenaciously to a particular system in the face of considerable contradictory evidence. Though such tenacity of belief may carry many disadvantages, it performs one valuable function: it enables the therapist to preserve equanimity in the face of considerable affect emerging within the transference or countertransference. Self-knowledge permits us to integrate all parts of ourselves, decreases ambiguity, permits a sense of effectance and mastery, and allows us to act in concert with our own best interests. An explanatory scheme also permits generalization and transfer of learning from the therapy setting to new situations in the outside world (akin to Peter Fonagy’s concept of epistemic trust discussed in Chapter 2). Psychotherapy promotes the client’s ability to transfer knowledge about how the world works from the therapy relationship to the world at large, propelling the adaptive spiral. The great controversies arise when we discuss not the process or the purpose or the effects of explanation but the content of explanation. As we hope to make clear in Chapter 6, we think these controversies are irrelevant. When we focus on change rather than on self-understanding as our ultimate goal, we can only conclude that insight is of greatest value if it leads to personal change. Each clarifying or interpretive act of the therapist is ultimately designed to exert leverage on the client’s will to change. Imitative Behavior (Identification) Group therapy participants rate imitative behavior among the least helpful of the twelve therapeutic factors. However, we learned from debriefing interviews that the five items in this category seem to have failed to describe this therapeutic mode in ways that evoked clients’ identification of it or experiences with it. The items failed to distinguish clearly between mere mimicry, which apparently has only a restricted value for clients, and the acquisition of general styles and strategies of behavior, which may have considerable value. To clients, conscious mimicry is an especially unpopular concept as a therapeutic mode because it suggests subordination or a relinquishing of individuality—a basic fear of many group participants. On the other hand, clients may acquire from others a general strategy that may be used across a variety of personal situations. Members of groups for medically ill patients and in twelve-step groups often benefit from seeing other members manage a shared problem effectively.47 This process also works at both overt and subtle levels. Clients may begin to approach problems by considering, consciously or unconsciously, what some other member or the therapist would think or do in the same situation. (Recall the vignette earlier in which Meena was empowered by Samantha’s risk-taking). If the therapist is tolerant and flexible, then clients may also adopt these traits. If the therapist is judiciously self-disclosing and accepts his or her limitations without becoming insecure or defensive, then clients are more apt to learn to accept their personal shortcomings.48 The group leader’s capacity, and even courage, to acknowledge personal disappointment and imperfection reduces clients’ dread of shame about their imperfections and disappointments.49 Initially, imitative behavior is, in part, an attempt to gain approval, but it does not end there. The more psychologically intact clients retain their autonomy and flexibility as they road-test new behaviors, and they soon realize that some of those changes result in greater acceptance by others. Such acceptance can can then lead these clients to change their self-concept and self-esteem in the manner described in Chapter 3, and an adaptive spiral is instigated. It is also possible for an individual to identify with aspects of two or more other people, resulting in an amalgam. Although the behaviors of others are imitated, the amalgam represents a creative synthesis, a highly innovative individualistic identity. What of “spectator therapy”? Is it possible that clients may learn much from observing the solutions arrived at by others who have similar problems? We have no doubt that such learning occurs in the therapy group. Every experienced group therapist has at least one story of a member who came regularly to the group for months on end, was extremely inactive, and finally terminated therapy much improved. I (IY) clearly remember Rod, who was so shy, isolated, and socially phobic that in his adult life he had never shared a meal with another person. When I introduced him into a rather fast-paced group, I was concerned that he would be in over his head. And, in a sense, he was. For months he sat and listened in silent amazement as the other members interacted intensively with one another. That was a period of high learning for Rod: simply to be exposed to the possibilities of intimate interaction enriched his life. But then things changed! The group began to demand more reciprocity and placed great pressure on him to participate more personally in the meetings. Rod grew more uncomfortable and ultimately, with my encouragement, decided to leave the group. Since he and I worked at the same university, our paths crossed several times in the ensuing years, and he never failed to inform me how important and useful the group had been. It had shown him what was possible and how individuals could engage one another, and it offered him an internal reference point to which he could turn for reassurance as he gradually reached out to others in his life. Clients learn not only from observing the substantive work of others who are like them but also from watching the process of the work. In that sense, imitative behavior is a transitional therapeutic factor that permits clients subsequently to engage more fully in other aspects of therapy. Proof of this is to be found in the fact that one of the five imitative behavior items (item 37, Seeing that others could reveal embarrassing things and take other risks and benefit from it helped me to do the same) was tied for eighth place in the rankings of sixty therapeutic factors. A large-scale study in the Netherlands found that clients considered identification to be more important in the early stages of therapy, when novice members looked for more senior members with whom to identify.50 Watching group interaction contributes to group members developing an observing ego onto their interpersonal interactions.51 Family Reenactment (The Corrective Recapitulation of the Primary Family Group) Family reenactment, subsequently modified to the corrective recapitulation of the primary family group—a therapeutic factor highly valued by many therapists—is not generally considered helpful by most group members. Unsurprisingly, little has been published in this specific area over the past many years. The clinical populations that do place a high value on this factor are very specific: groups for incest survivors52 and groups for sex offenders.53 For these members the early failure of the family to protect and care for them looms as a powerful issue. That this factor is not cited often by most group members, though, should not surprise us, since it operates at a different level of awareness from such explicit factors as catharsis or universality. Family reenactment becomes more a part of the general horizon against which the group is experienced. Few therapists will deny that the primary family of each group member is an omnipresent specter haunting the group therapy room. That specter, carrying a lifetime of family memories, will undoubtedly influence how clients express interpersonal distortions, what roles they assume in the group, and how they view their group leaders. There is little doubt in our minds that the therapy group reincarnates the primary family. It acts as a time machine, flinging the client back several decades and evoking deeply etched ancient memories and feelings. In fact, this phenomenon is one of the major sources of power of the therapy group. In my (IY) last meeting with a group before departing for a year’s sabbatical, a client related the following dream: “My father was going away for a long trip. I was with a group of people. My father left us a thirty-foot boat, but rather than giving it to me to steer, he gave it to one of my friends, and I was angry about this.” This is not the place to discuss this dream fully. Suffice it to say that the client’s father had deserted the family when the client was young, leaving him to be tyrannized thereafter by an older brother. The client said that this was the first time he had thought of his father in years. The events of the group—my departure, my place being taken by a new therapist, the client’s attraction to the co-therapist (a woman), his resentment toward another dominating member in the group—all acted in concert to awaken long-slumbering memories. Clients reenact early family scripts in the group and, in successful group therapy, they experiment with new behaviors and break free from the rigid family roles into which they had long been locked. These themes may be particularly prominent when sibling transferences or rivalries develop regarding the group or group leader’s attention, interest, and care.54 While we believe these are important phenomena in the therapeutic process, it is altogether a different question whether the group should focus explicitly on them. We think not, as this process is part of the internal, generally silent, homework of the group member. Shifts in our perspective on the past occur because of the vitality of the work in the present—not through a direct summons and inquiry of the spirits of the past. There are, as we will discuss in Chapter 6, many overriding reasons for the group to maintain an ahistorical focus even as we move between past and present in our interactions. > Gordon, a chronically depressed man, shared with the group that he’d had a lot of physical pain recently and had learned that he had a hernia in his groin that would require surgery. He wanted us to know how apprehensive he was about the pending surgery and sought some support from the group, even if, in so doing, he needed to, in his words, “drop his pants” in the meeting to tell us about it.
Later in that session, when I (ML) responded to an important self-disclosure made by another member of the group about a sexual encounter, I commented that Gordon’s “dropping of his pants” had encouraged others to take more risks in the meeting.
In the next session, Gordon commented, “Your joking about ‘dropping my pants’ hurt me deeply.” He said he felt that I had been teasing him and had humiliated him in front of the group. He had not been aware of experiencing that feeling in the actual moment in the session, but it had built over the days between our meetings.
“I’m so sorry,” I said. “I was hoping to support your openness, but my comment had an unintentional and hurtful impact. Could we examine what that might represent?”
Gordon seemingly welcomed my apology but was unable to do anything more with the exploration. His reference to feeling humiliated, however, evoked in another group member, Sally, a recollection of a story Gordon had shared with us sessions before. “I remember you describing your father’s glee in humiliating you when the extended family would get together for dinners. I remember that he would ask you to stand up at the table and answer arithmetic questions that he knew you couldn’t do.”
I asked Gordon if there was any possible connection, and he became quite energized. “Yes, right on, I felt like you were embarrassing me in front of the group, like he did in front of my family.”
“Gordon, please believe me, I had no such intention in mind.”
“I do believe you. Thanks. Never once did my father apologize to me.” << Existential Factors The category of existential factors was almost an afterthought. My (IY) colleagues and I first constructed the Q-sort instrument with eleven major factors. It appeared neat and precise, but something was missing. Important sentiments expressed by both clients and therapists had not been represented, so we added a factor consisting of these five items: 1. Recognizing that life is at times unfair and unjust 2. Recognizing that ultimately there is no escape from some of life’s pain or from death 3. Recognizing that no matter how close I get to other people, I must still face life alone 4. Facing the basic issues of my life and death, and thus living my life more honestly and being less caught up in trivialities 5. Learning that I must take ultimate responsibility for the way I live my life, no matter how much guidance and support I get from others Several issues are represented in this cluster: responsibility, basic isolation, contingency, the capriciousness of existence, the recognition of our mortality, and the ensuing consequences for the conduct of our life. What to label this category? I finally settled, with some hesitation, on existential factors, meaning that all these factors relate to existence—to our confrontation with the human condition. This confrontation informs us of the four harsh existential facts of life: our mortality, our freedom and responsibility for constructing our own life design, the isolation we experience from being thrust alone into existence, and our search for life meaning despite the misfortune of having been born into a universe without intrinsic meaning. These four harsh facts of life later were to provide the structure of my (IY) book Existential Psychotherapy. It is clear that the existential items strike responsive chords in clients, and many cite some of the five items as having been crucially important to them. In fact, the entire category of existential factors is often ranked highly, ahead of other valued therapeutic factors such as universality, altruism, recapitulation of the primary family experience, guidance, identification, and instillation of hope. Item 60, Learning that I must take ultimate responsibility for the way I live my life, no matter how much guidance and support I get from others, was ranked fifth overall of the sixty items. Similar findings are reported by other researchers. Every project that includes an existential category reports that subjects rank that category at least in the upper 50th percentile. In some studies, for example, with therapy groups in prison, in day hospitals, in psychiatric hospitals, and in alcohol treatment groups, the existential category is ranked among the top three factors.55 Existential factors are also central to many of the current group therapy interventions for the seriously medically ill and in groups for caregivers of ill family members.56 A group of older women ranked existential factors first, as did a sample of sixty-six patients on an alcoholism treatment unit.57 What unites these divergent clinical populations is the participants’ awareness of immutable limits in life—limits of time, power, or health. Even in groups led by therapists who do not conceptualize existential factors as relevant, the existential factors are highly valued by the group members.58 It is important to attend to our data. Obviously, existential factors in therapy deserve far more consideration than they generally receive. Surveys of senior group therapists consistently endorse the emphasis on relationships and personal choice.59 Unsurprisingly, existentially informed group therapies are even more prominent in the psychological care of medically ill and cancer patients, for whom mortal illness is a powerful existential force, and are generally more effective than general support groups alone.60 Even therapists who nominally adhere to other orientations are often surprised when they look deeply at their techniques and at their basic view of the human situation and find that they are existentially oriented.61 If you feel that we are more than a sum of parts, that some of the central features that make us human—purpose, responsibility, sentience, will, values, courage, spirit—should be part of our therapeutic focus, then to that degree you have an existentialist sensibility. I (IY) must be careful not to slip off the surface of these pages and glide into another book. This is not the place to discuss in any depth the existential frame of reference in therapy. I refer interested readers to my book Existential Psychotherapy.62 The existential therapeutic approach—with its emphasis on awareness of death, freedom, isolation, and life purpose—has been, until recently, far more acceptable to the European therapeutic community than to the American one. The European philosophic tradition, the geographic and ethnic confinement, and the greater familiarity with limits, war, death, and uncertain existence all favored the spread of the existential influence. The American zeitgeist of expansiveness, optimism, limitless horizons, and pragmatism was instead fertile ground for the scientific positivism proffered by a mechanistic Freudian metaphysics or a hyperrational, empirical behaviorism (strange bedfellows!). Morris Nitsun has described how the European and American cultures, influenced by their histories of wars, illness, and the development of nationhood, have shaped the dominant models of group therapy on each continent. Our psychotherapy models are inevitably influenced by the societies in which they are embedded.63 Our conceptual models continue to evolve. During the past six decades, there have been major developments in American psychotherapy, among them the emergence of what has come to be known as the third force in American psychology (after Freudian psychoanalysis and Watsonian behaviorism). This force, often labeled “existential” or “humanistic,” has had an enormous influence on modern therapeutic practice. This evolution continues as we recognize limitations of earlier models and expand our thinking to include spiritual, multiculturalist, and social justice dimensions.64 We have done more than import the European existential tradition; we have Americanized it. Thus, although the syntax of humanistic psychology is European, the accent is unmistakably New World. The European focus is on the tragic dimensions of existence, on limits, on facing and taking into oneself the anxiety of uncertainty and nonbeing. The American humanistic psychologists, on the other hand, speak less of limits and contingency than of human potentiality; less of acceptance than of awareness; less of anxiety than of peak experiences and oceanic oneness; less of life meaning than of self-realization; less of apartness and basic isolation than of “I-Thou” and meaningful encounter. Of course, when a basic doctrine has a number of postulates and the accent of each is systematically altered in a specific direction, there is a significant risk of divergence from the original doctrine. To some extent this has occurred; some humanistic psychologists have lost touch with their existential roots and espouse a monolithic goal of self-actualization, using quick techniques that promise personal transformation. This is a most unfortunate development. It is important to keep in mind that the existential approach in therapy is not a set of technical procedures, but, basically, an attitude, a sensibility toward the facts of life inherent in the human condition. Existential therapy is a dynamic approach based on concerns that are rooted in existence. Earlier we mentioned that a “dynamic” approach refers to a therapy that assumes that the deep structures of personality encompass forces that are in conflict with one another, and that these forces exist at different levels of awareness; indeed, some exist outside of conscious awareness. But what about the content of the internal struggle? The existential view of the content differs greatly from the view taken in other theories of dynamic systems. A traditional psychoanalytic approach, for example, addresses the struggle between the individual’s fundamental drives (primarily sexual and aggressive) and an environment that frustrates satisfaction of those drives. Alternatively, a self-psychology approach would attend to the individual’s efforts to preserve a stable sense of self as vital and worthwhile in the context of affirming or disappointing self-object relationships, while a modern analytic approach would address the transferences and resistances to emotional engagement. The existential approach holds that the human being’s paramount struggle is with the unavoidable “givens” of existence—the ultimate concerns of the human condition, which include death, isolation, freedom, and meaninglessness. Anxiety emerges from basic conflicts in each of these realms: (1) we wish to continue to be, and yet are aware of our inevitable death; (2) we crave imposed structure, and yet must confront the truth that we are the authors of our own life design, and our beliefs and neural apparatus are responsible for the form of our reality—underneath us there is Nichts, groundlessness, the abyss; (3) we desire contact and protection, to be part of a larger whole, yet experience the unbridgeable gap between self and others; and (4) we are meaning-seeking creatures thrown into a world that has no intrinsic meaning. The items in the Q-sort that resonated for the subjects in the study reflected some of these painful truths about existence. Group members realized that there were limits to the guidance and support they could receive from others and that the ultimate responsibility for the conduct of their lives was theirs alone. They learned also that though they could be close to others, there was a point beyond which they could not be accompanied: there is a basic aloneness to existence that must be faced and borne. Many clients learned to face their limitations and their mortality with greatercandor and courage. Coming to terms with their own deaths in a deeply authentic fashion permitted them to cast the troublesome concerns of everyday life in a different perspective. It permitted them to trivialize life’s trivia. We often ignore these existential givens until life events demand our attention. We may at first respond to illness, bereavement, and trauma with denial, but ultimately the impact of these life-altering events may break through. They create a therapeutic opportunity to catalyze constructive changes in oneself, in one’s relationships, and in one’s relationship to life in general. Posttraumatic growth occurs regularly when individuals are helped to process the traumatic disruptions in their lives.65 In one study, after attending ten sessions of group therapy, women with early-stage breast cancer were more optimistic and less depressed and anxious than other women with cancer who did not attend group therapy. They were also more likely to conclude that their cancer had contributed positively to their lives by causing them to realign their life priorities.66 In another study, a similar group showed a significant reduction in levels of the stress hormone cortisol.67 Studies comparing different types of groups for individuals with advanced cancer are also notable. The existentially informed, meaning-focused group therapies produced a higher quality of life and a greater sense of spiritual well-being than the traditional support groups, with participants experiencing less depression, less hopelessness, and less distress from physical symptoms.68 The course of therapy for Sheila, a client who at the end of treatment selected the existential Q-sort items as having been instrumental in her improvement, illustrates many of these points: > A twenty-five-year-old perennial student, Sheila, complained of depression, loneliness, purposelessness, and severe gastric distress for which no organic cause could be found. In a pregroup individual session, she lamented repeatedly, “I don’t know what’s going on!”
I (IY) could not understand precisely what she meant, and since this complaint was embedded in a litany of self-accusations, I soon forgot it. However, she did not understand what was happening to her in the group, either: she could not understand why others were so uninterested in her, why she had developed a host of somatic ailments, why she entered sexually masochistic relationships, or why she so idealized the therapist.
In the group, Sheila was boring and absolutely predictable. Before every utterance, she scanned the sea of faces in the group searching for clues to what others wanted and expected. She was willing to be almost anything so as to avoid offending others and possibly driving them away from her. (Of course, she did drive others away, not from anger but from boredom.) Sheila was in chronic retreat from life, and the group tried endless approaches to halt the retreat, and to find Sheila within the cocoon of compliance she had spun around herself.
No progress occurred until the group stopped encouraging Sheila, stopped attempting to force her to socialize, to study, to write papers, to pay bills, to buy clothes, to groom herself, but instead urged her to consider the blessings of failure. What was there in failure that was so seductive and so rewarding? Quite a bit, it turned out! Failing kept her young, kept her protected, kept her from deciding. Idealizing the therapist served the same purpose. Help was out there. He knew the answers. Her job in therapy was to enfeeble herself to the point where the therapist could not in all good conscience withhold his royal touch.
A critical event occurred when she developed an enlarged axillary lymph node. She had a biopsy performed, and later that day came to the group still fearfully awaiting the results (which ultimately proved the enlarged node to be benign). Never before had she so closely considered her own death, and we helped Sheila plunge into the terrifying loneliness she experienced. There are two kinds of loneliness: the primordial, existential loneliness that Sheila confronted in that meeting, and social loneliness, an inability to be with others.
Social loneliness is commonly and easily worked with in a group therapeutic setting. Existential loneliness is more hidden, obscured by the distractions of everyday life, and more rarely faced. Sometimes groups confuse the two and make an effort to resolve or to heal a member’s basic loneliness. But, as Sheila learned that day, it cannot be taken away; it cannot be resolved; it can only be known and ultimately embraced as an integral part of existence.
Rather quickly, then, Sheila changed. She reintegrated far-strewn bits of herself. She began to make decisions and to take over the helm of her life. She commented, “I think I know what’s going on” (I had long forgotten her initial complaint). More than anything else, she had been trying to avoid the specter of loneliness. I think she tried to elude it by staying young, by avoiding choice and decision, by perpetuating the myth that there would always be someone who would choose for her, would accompany her, would be there for her. << Choice and freedom invariably imply loneliness, and, as Erich Fromm pointed out long ago in Escape from Freedom, freedom often holds more terror for us than tyranny.69 TURNING BACK AGAIN TO TABLE 4.1, LET US CONSIDER ITEM 60, which so many clients rated so highly: Learning that I must take ultimate responsibility for the way I live my life, no matter how much guidance and support I get from others. In a sense, this is a double-edged factor in group therapy. Group members learn a great deal about how to relate better with others, how to develop greater intimacy with others, and how to give help to others and ask for help from others. At the same time, they discover the limits of intimacy; they learn what they cannot obtain from others. It is a harsh lesson and leads to both despair and strength. One cannot stare at the sun for very long, and Sheila on many occasions looked away and avoided her dread. But she was always able to return to it and, by the end of therapy, had made major shifts within herself. An important concept in existential therapy is that human beings may relate to the ultimate concerns of existence in one of two possible modes. On the one hand, we may suppress or ignore our situation in life and live in what Martin Heidegger termed a state of forgetfulness of being.70 In this everyday mode, we live in the world of things, in everyday diversions; we are absorbed in chatter, tranquilized, lost in the “they”; we are concerned only about the way things are. On the other hand, we may exist in a state of mindfulness of being, a state in which we marvel not at the way things are, but that they are. In this state, we are aware of being; we live authentically; we embrace our possibilities and limits; we are aware of our responsibility for our lives. (This state is captured well by Jean-Paul Sartre’s definition of responsibility: “To be responsible is to be the ‘uncontested author of…’”)71 Being aware of one’s self-creation in the authentic state of mindfulness of being provides one with the power to change and the hope that one’s actions will bear fruit. Thus, the therapist must pay special attention to the factors that transport a person from the everyday to the authentic mode of existing. One cannot create such a shift merely by bearing down, by gritting one’s teeth. But there are certain jolting experiences (often referred to in the philosophical literature as “boundary experiences”) that effectively transport one into the mindfulness-of-being state. Some group leaders attempt to generate such experiences by using a form of existential shock therapy. With a variety of techniques, they try to bring clients to the edge of the abyss of existence. We have seen leaders begin personal growth groups, for example, by asking clients to compose their own epitaphs. An extreme experience—such as Sheila’s encounter with a possibly malignant tumor—is a good example of a boundary experience: an event that brings one sharply back to reality and helps one put one’s concerns in their proper perspective. Extreme experience, however, occurs in its natural state only rarely during the course of a therapy group, and the adept leader finds other ways to introduce these factors. The growing emphasis on brief therapy offers an excellent opportunity: the therapist may use the looming end of therapy or the departure of a member to urge clients to consider other terminations, including death, and to reconsider how to improve the quality and satisfaction of their remaining time. It is in this domain that the existential and interpersonal intersect as clients begin to ask themselves fundamental questions: What choices do I exercise in my relationships and in my behavior? How do I wish to be experienced by others? Am I truly present and engaged in this relationship, or am I managing the relationship inauthentically to reduce my anxiety? Do I care about what this person needs from me, or am I motivated by my constricted self-interest? Every encounter matters and may set in motion far-reaching impacts. I (ML) experienced a powerful illustration of this principle when discussing group psychotherapy in a regional affiliate of the American Group Psychotherapy Association. I had returned there twelve years after my first two-day visit, and as I had done twelve years previously, I blended lectures with demonstration groups. These groups were composed of volunteers who participated in three sessions observed by the rest of the attendees. These are not psychotherapy groups, of course, but deeply personal material does emerge. > In the last of our three sessions, I stressed our time limit and the importance of using time well, making every moment count, and reducing regrets of things unsaid. Susan, a therapist in her fifties, asked for time and then floored me and everyone in the room. “I have been waiting twelve years for this opportunity to come and participate in this demonstration group with you. I want to tell you that the last time you were here, you saved my life. Your presentation about group therapy for women with metastatic breast cancer and what you said about not leaving things unaddressed pushed me into a mammogram that I had avoided because I dreaded the prospect of being touched and prodded in that way. I booked an appointment shortly after that session and was shocked to learn I had an aggressive form of breast cancer. I was treated for it effectively at that time and I have been cancer-free since. I believe my characteristic neglect and avoidance would have resulted in this becoming metastatic disease and killing me. I have never put myself forward for a demo group before even though I have attended dozens of these trainings. But I was not going to miss this opportunity.”
I acknowledged the profound impact her disclosure had on me. I thanked her and told her that what she had shared would stay with me forever. It underscored, better than I could have possibly imagined, the theme I had hoped to demonstrate that day about using time meaningfully and not leaving things unaddressed. << Our capacity for denial is enormous, and it is the rare group that perseveres and does not slip back into less threatening concerns. Natural events in the course of a group—illness, death, termination, and loss—may jolt the group back to a more existential frame of mind, but always temporarily. In 1974, I (IY) began to lead groups of individuals who lived continuously in the midst of extreme experience.73 All the members had a terminal illness, generally metastatic carcinoma, and all were entirely aware of the nature and implications of their illness. I learned a great deal from these groups, especially about the fundamental but concealed issues of life that are so frequently neglected in traditional psychotherapy (see Chapter 15 for a detailed description of this group and current applications of the supportive-expressive group approach). As we reflect back on our therapy groups for cancer patients, several features stand out. For one thing, the members were deeply supportive to one another, and being useful to someone else drew them out of morbid self-absorption and provided them with a sense of purpose and meaning. Almost every terminally ill person we have worked with has expressed deep fear of helpless immobility—not only of being a burden, but of being useless and without value to others. Living then becomes reduced to pointless survival, and the individual searches within, ever more deeply, for meaning. The group offered these participants the opportunity to find meaning outside themselves by extending help to another person. By caring for others, they found the sense of purpose that so often eludes sheer introspective reflection. These approaches, these avenues to self-transcendence, if well-traveled, can increase one’s sense of meaning and purpose as well as one’s ability to bear what cannot be changed. Finding meaning in the face of adversity can be transformative.74 Long ago, Nietzsche wrote: “He who has a why to live can bear with almost any how.”75 It was clear, through observation and empirical research, that the members of these groups who plunged most deeply into themselves, who confronted their fate most openly and resolutely, passed into a richer mode of existence.76 Their life perspective was radically altered, and the trivial, inconsequential diversions of life were seen for what they were. Their neurotic phobias diminished. They appreciated more fully the elemental features of living: the changing seasons, the loving of others, and the joy in the seemingly mundane, such as meeting one’s child after school. Rather than resignation, powerlessness, and restriction, some members experienced a great sense of liberation and autonomy. Some even spoke of the gift of cancer. What some considered tragic was not their death per se, but that they had learned how to live life fully only after being threatened by serious illness. They wondered if it was possible to teach their loved ones this important lesson earlier in life, or whether it could be learned only in extremis. It may be that, though the act of death ends life, the idea of death revitalizes life: death becomes a co-therapist pushing the work of psychotherapy ahead. What can you as therapist do in the face of the inevitable? I think the answer lies in the verb to be. You do by being, by being there with the client. Presence is the hidden agent of help in all forms of therapy.77 Clients looking back on their therapy rarely remember a single interpretation you uttered, but they always remember your presence, that you were there with them. It is asking a great deal of the therapist to join such a group, yet it would be hypocrisy not to join. The group does not consist of you (the therapist) and them (the dying); it is we who are dying, we who are banding together in the face of our common condition. In my (IY) book The Gift of Therapy, I propose that the most accurate or felicitous term for the therapeutic relationship might be “fellow traveler.” The group well demonstrates the double meaning of the word apartness: we are separate, lonely, apart from, but also a part of. One group member put it elegantly when she described herself as a lonely ship in the dark. Even thoughno physical mooring could be made, it was nonetheless enormously comforting to see the lights of other ships sailing the same water. COMPARATIVE VALUE OF THE THERAPEUTIC FACTORS: DIFFERENCES BETWEEN CLIENTS’ AND THERAPISTS’ VIEWS Do clients and therapists agree about what helps in group psychotherapy? Research comparing therapists’ and clients’ assessments is instructive. First, keep in mind that therapists’ published views of the range of therapeutic factors are broadly analogous to the factors we have described.78 But, of course, leaders from different ideological schools differ in their weighting of the therapeutic factors, even though they often resemble one another in the way they actually practice psychotherapy.79 The research data tells us that therapists and clients differ in their valuation of the group therapeutic factors. A study of one hundred acute inpatient group members and their thirty behaviorally oriented therapists showed that the therapists and clients differed significantly in their ranking of therapeutic factors. The therapists valued modeling and experimenting with new behaviors, whereas the group members valued self-responsibility, self-understanding, and universality.80 Another study showed that members of alcohol addiction groups ranked existential factors far higher than their therapists did.81 It should not be surprising that substance abuse clients value accountability and personal responsibility highly. These factors are cornerstones of twelve-step groups. Fifteen HIV-positive men treated in time-limited cognitive-behavioral therapy groups for depression also cited different therapeutic factors than their therapists did. Members selected social support, cohesion, universality, altruism, and existential factors, whereas the therapists (in line with their ideological school) considered cognitive restructuring as the mutative agent.82 A large survey of prison therapy groups noted that inmates agreed with their group leaders about the importance of interpersonal learning, but valued existential factors far more highly than their therapists did.83 As noted earlier, incest victims in group therapy highly value the therapeutic factor of family reenactment.84 Therapists are wise to be alert to these divergences and to honor the client relationship over professional ideology. This issue is not restricted to group therapy. Client-therapist discrepancies on therapeutic factors also occur in individual psychotherapy. A large study of psychoanalytically oriented therapy found that clients attributed their successful therapy to relationship factors, whereas their therapists gave precedence to technical skills and techniques.85 In general, analytic therapists value the coming to consciousness of unconscious factors and the subsequent linkage between childhood experiences and current symptoms far more than their clients do. Indeed, their clients often deny the importance or even the existence of these elements in therapy and instead emphasize the personal elements of the relationship and the encounter with a new, accepting type of authority figure. Keep in mind that it is the client perspective that matters most.86 Such client-therapist divergence may strain or even rupture the alliance if the therapist fails to respect and understand the client’s attribution of value in the therapy.87 A turning point in the treatment of one client starkly illustrates the differences. In the midst of treatment, the client had an acute anxiety attack and was seen by the therapist in an emergency session. Both therapist and client regarded the incident as critical, but for very different reasons. To the therapist, the emergency session unlocked the client’s previously repressed memories of early incestuous sex play and facilitated a working-through of important Oedipal material. The client, however, entirely dismissed the content of the emergency session and instead valued the relationship implications: the caring and concern expressed by the therapist and his willingness to see him in the middle of the night. A similar discrepancy between client and therapist views of therapy is described in Every Day Gets a Little Closer, a book I (IY) coauthored with a client.88 Throughout the treatment, she and I wrote independent, impressionistic summaries of each meeting and handed them in, sealed, to my secretary. Every few months we read each other’s summaries, and we discovered that we valued very different aspects of the therapeutic process. All my elegant interpretations? She never even heard them! What she remembered and treasured were the soft, subtle, personal exchanges, which, to her, conveyed my interest and caring for her. Reviews of process and outcome research reveal that clients’ ratings of therapist engagement and empathy are more predictive of therapeutic success than therapists’ ratings of these same variables.89 These findings compel us to pay close attention to the client’s view of the most salient therapeutic factors. In research as in clinical work, we do well to heed the adage: Listen to the client. To summarize: Therapists and their clients differ in their views about important therapeutic factors. Clients consistently emphasize the relationship and the personal, human qualities of the therapist, whereas therapists attribute their success to their techniques. When, in group therapy, the therapist-client discrepancy is too great, and therapists emphasize therapeutic factors that are incompatible with the needs and capacities of the group members, the therapeutic enterprise will be derailed: clients will become bewildered and resistant, and therapists will become discouraged and exasperated. The therapist’s capacity to respond to client vulnerability with warmth and tenderness is pivotal, and may lie at the heart of the transformative power of therapy. THERAPEUTIC FACTORS: MODIFYING FORCES It is not possible to construct an absolute hierarchy of therapeutic factors. There are many modifying forces: therapeutic factors are influenced by the type of group therapy, the stage of therapy, extragroup forces, and individual differences. The therapist’s flexibility and responsiveness are better guides than any arbitrary hierarchy of value could be in maximizing the use of the therapeutic factors. Therapeutic Factors in Different Group Therapies Different types of group therapy use different clusters of therapeutic factors. Consider, for example, the therapy group on an acute psychiatric inpatient ward. Members of inpatient therapy groups rarely select the same constellation of three factors (interpersonal learning, catharsis, and self-understanding) that most members of outpatient groups cite.90 Rather, they select a wide range of therapeutic factors that reflect both the heterogeneous composition of inpatient therapy groups and the cafeteria theory of improvement in group therapy. Clients who differ greatly from one another in ego strength, motivation, goals, and type and severity of psychopathology meet in the same inpatient group and, accordingly, select and value different aspects of the group procedure. Many more inpatients than outpatients select the therapeutic factors of instillation of hope and existential factors. Instillation of hope looms large in inpatient groups because so many individuals enter the hospital in a state of utter demoralization. Until the individual acquires hope and the motivation to engage in treatment, no progress will be made. Often the most effective antidote to demoralization is the presence of others who have recently been in similar straits and discovered a way out of despair. Existential factors (defined on the research instruments generally as “assumption of ultimate responsibility for my own life”) are of particular importance to inpatients, because often hospitalization confronts them with the limits of other people: external resources have been exhausted; family, friends, and therapists have failed; they have hit bottom and realize that, in the final analysis, they can rely only on themselves. (On one inpatient Q-sort study, the assumption of responsibility, item 60, was ranked first of the sixty items.)91 A vast range of homogeneously composed groups exist. The range of therapeutic factors chosen by the members of various groups is summarized in the box “Therapeutic Factors and Diverse Therapy Groups.” THERAPEUTIC FACTORS AND DIVERSE THERAPY GROUPS • Alcoholics Anonymous members emphasize the instillation of hope, imparting information, universality, and cohesion.92 Successfully treated clients in a fifteen-session group treatment of drug addiction in Egypt reported high valuation of the therapeutic factors of catharsis, cohesion, and interpersonal learning; identification was ranked lowest. These findings are remarkably similar to the findings described in successfully treated general outpatients in North America.93 • Textual analysis of transcriptions of tape-recorded therapy sessions of an interactional inpatient therapy group for patients with concurrent addiction and mental illness revealed an evolution in therapeutic factors valuation beginning with early expression of feelings, learning about group therapy, and feeling cared for, and later maturing into catharsis and group cohesion.94 • Children treated in sixteen sessions of group therapy for emotional and behavioral difficulties demonstrated, through a posttreatment analysis of critical incidents, that the most important therapeutic factor was “relationship-climate.” Feeling safe, accepted, and that they belonged ranked higher for the children than learning and problem-solving factors, suggesting that an important developmental need was met in the group. Self-disclosure emerged only after that sense of belonging was secure.95 • Participants of occupational therapy groups most valued the factors of cohesiveness, instillation of hope, and interpersonal learning.96 • Members of psychodrama groups in Israel, despite differences in culture and treatment format, selected factors consistent with those selected by group therapy outpatients: interpersonal learning, catharsis, group cohesiveness, and self-understanding.97 • Members of self-help groups (women’s consciousness raising, bereaved parents, widows, heart surgery patients, and mothers) commonly chose factors of universality, followed by guidance, altruism, and cohesiveness.98 • Members of an eighteen-month-long group of spouses caring for a partner with a brain tumor chose universality, altruism, instillation of hope, and the provision of information.99 • Psychotic clients with intrusive, controlling, auditory hallucinations successfully treated in cognitive-behavioral therapy groups valued universality, hope, and catharsis. For them, finally being able to talk about their voices and feeling understood by peers was enormously valuable.100 • Spousal abusers in a psychoeducational group selected the imparting of information as a chief therapeutic factor.101 • Adolescents in learning disability groups cited the effectiveness of “mutual recognition”—of seeing oneself in others and feeling valued and less isolated.102 • Geriatric group participants confronting limits, mortality, and the passage of time selected existential factors as critically important.103 When therapists form a new therapy group in some specialized setting or for some specialized clinical population, the first step is to determine the appropriate goals and, after that, the therapeutic factors most likely to help that particular group reach those goals. Everything else, all matters of therapeutic technique, follow from that framework. In all groups, we can deepen our clients’ therapeutic experience through thoughtful and deliberate employment of the therapeutic factors in the service of creating and sustaining an energized, therapeutic group climate marked by empathy and connectedness.104 We should always be asking ourselves, “How can I maximize this therapeutic opportunity?” Thus, it is vitally important to keep in mind that there is persuasive research suggesting that different therapeutic factors can be effective in group therapy at different points in time and for different purposes. For example, consider more structured groups, such as a time-limited psychoeducational group for panic attacks, whose members may receive considerable benefit from group leader instruction on cognitive strategies for preventing and minimizing the disruptiveness of the attacks (guidance). The experience of being in a group of people who suffer from the same problem (universality) is also likely to be very comforting. Although difficulties in relationships may indeed contribute to the clients’ symptoms, an undue focus on the therapeutic factor of interpersonal learning would not be warranted given the time frame of the group. Cognitive-behavioral group therapy is enhanced as well by the leader’s attention to the utilization of therapeutic factors: remoralization through instillation of hope; reduced isolation and stigma through universality; a sense of belonging through cohesion; acquisition of knowledge through guidance; self-esteem enhancement through altruism; and skill development through socialization and practice.105 Understanding the client’s experience of the therapeutic factors can lead to enlightened and productive group innovations. An excellent illustration is a multimodal group approach for bulimia nervosa that offers three effective therapeutic components: imparting information, learning coping skills, and exploring interpersonal relationships. This twelve-week group starts with a psychoeducation module about bulimia and nutrition; next is a cognitive-behavioral module that examines distorted cognitions about eating and body image; and the group concludes with an interpersonally oriented group segment that examines here-and-now relationship concerns and their impact on eating behaviors.106 Therapeutic Factors and Stages of Therapy Intensive interactional group therapy exerts its chief therapeutic power through interpersonal learning (encompassing catharsis, self-understanding, and interpersonal input and output) and group cohesiveness, but the other therapeutic factors play an indispensable role in the intensive therapy process. To appreciate the interdependence of the therapeutic factors, we must consider the entire group process from start to finish.107 Many clients expressed difficulty in rank-ordering therapeutic factors because they found different factors helpful at different stages of therapy. Factors of considerable importance early in therapy may be far less salient late in the course of treatment. In the early stages of development, the the group’s chief concerns are with establishing boundaries and maintaining membership. In this stage, factors such as the instillation of hope, guidance, and universality are especially important.108 The first dozen meetings of a group present a high-risk period for potential dropouts, and it is often necessary to awaken hope in the members in order to keep them attending through this critical phase. Factors such as altruism and group cohesiveness operate throughout therapy, but their nature changes with the stage of the group. Early in therapy, altruism takes the form of offering suggestions or helping one another talk by asking appropriate questions and giving attention. Later it may take the form of a more profound caring and presence. Group cohesiveness operates as a therapeutic factor at first by means of group support, acceptance, and the facilitation of attendance, and later by means of the interrelation of group esteem and self-esteem and through its role in interpersonal learning. It is only after the development of group cohesiveness that members may engage deeply and constructively in the self-disclosure, feedback, confrontation, and conflict essential to the process of interpersonal learning. Cohesion continues to mount over time in long-term groups and requires the therapist’s ongoing focus and attention.109 Therapists must appreciate this necessary group and individual developmental sequence to help prevent early group dropouts. In a study of therapeutic factors in long-term inpatient treatment in Germany, clinical improvement was related to the experience of early cohesion, which set the stage for greater personal self-disclosure, which generated the interpersonal feedback that produced behavioral and psychological change.110 An outpatient study demonstrated that the longer group members participated in the group, the more they valued cohesiveness, self-understanding, and interpersonal output.111 In a study of twenty six-session growth groups, universality and hope declined in importance through the course of the group, whereas the importance of catharsis increased.112 In a study of spouse abusers, universality was the prominent factor in early stages, while the importance of group cohesion grew over time.113 This emphasis on universality may be characteristic in the treatment of clients who feel shame or stigma. The cohesion that promotes change, however, is best built on a respect for and acceptance of personal differences, which take time to mature. In another study, psychiatric inpatients at first valued universality, hope, and acceptance, but later, when they participated in outpatient group psychotherapy, they valued self-understanding more, underscoring the relationship between therapeutic factors and the client’s trajectory of change.114 In summary, the therapeutic factors clients deem most important vary with the stage of group development. Clients’ needs and goals change during the course of therapy. In Chapter 2, we described a common sequence in which group members first seek symptomatic relief and then, during subsequent sessions, formulate new goals, often interpersonal ones of relating more deeply and honestly to others. Clients change, the group goes through a developmental sequence, and the therapeutic factors shift in primacy and influence during the course of therapy. Therapists begin by ensuring group integrity, safety, belonging, connection, and cohesion; progress into catharsis, self-understanding, and interpersonal learning; and end with consolidation, internalization, and accepting personal responsibility for change in one’s life. Therapeutic Factors Outside the Group Although we suggest that major behavioral and attitudinal shifts require a degree of interpersonal learning, occasionally group members make major changes without appearing to be fully invested in the group work. This brings up an important principle in therapy: The therapist or the group does not have to do the entire job. Forces outside of active treatment play a huge role in our clients’ outcomes, accounting for up to 40 percent of the variability in outcome.115 These extra-therapeutic forces include opportunities in employment, relationships, religion, community, and social relationships. And, of course, there are times when good fortune plays a role: various opportunities may arise in our clients’ lives at just the right time for them developmentally. Personality reconstruction as a therapeutic goal is as unrealistic as it is presumptuous. Our clients have many adaptive coping strengths that may have served them well in the past, and a boost from some event in therapy may be sufficient to help a client draw on these strengths. We have used the term “adaptive spiral” to refer to the process in which one change in a client begets changes in his or her interpersonal environment that beget further personal change. The adaptive spiral is the reverse of the vicious cycle in which so many clients find themselves ensnared—a sequence of events in which dysphoria has interpersonal manifestations that weaken or disrupt interpersonal bonds and consequently create further dysphoria. These points are documented when we ask clients about other therapeutic influences or events in their lives that occurred concurrently with their therapy course. In one sample of twenty clients, eighteen described a variety of extragroup therapeutic factors. Most commonly cited was a new or improved interpersonal relationship with one or more of a variety of figures (member of the opposite sex, parent, spouse, teacher, foster family, or new set of friends).116 Two clients claimed to have benefited by going through with a divorce that had long been pending. Many others cited successes at work, at school, or in their community that raised their self-esteem as they established a reservoir of real accomplishments. Perhaps these fortuitous, independent factors deserve credit, along with group therapy, for successful outcomes. In one sense, that is true: the external event augments therapy. Yet it is also true that the potential external event had often always been there; the therapy group simply mobilized members to take advantage of resources that had long been available to them in their environment. Clients in one study referred to these as “transfer factors,” that is, factors supporting the transfer of in-group skills and knowledge to home and work.117 Consider Bob, a lonely, shy, and insecure man who attended a time-limited twenty-five-session group. Though he spent considerable time discussing his fear about approaching women, and though the group devoted much effort to helping him, there seemed to be little change in his outside behavior. But at the final meeting of the group, Bob arrived with a big smile and a going-away present for the group: he brought in a profile he planned to post on an online dating site. The group eagerly listened to him as he described himself in a new and positive light that he attributed to the feedback he received in the group. Partners, lovers, dating apps, relatives, potential friends, social organizations, and academic or job opportunities are always out there, available, waiting for the client to seize them. The group may give a client only the necessary slight boost to allow him or her to exploit these previously untapped resources. At times, the group may end with no evidence of what the group may have launched. Therapists are often pleasantly surprised to get an email years after a client has ended group therapy with an update about personal and professional achievements. Later, when we discuss combined treatment, we will emphasize the point that therapists who continue to see clients in individual therapy long after the termination of the group often learn that members make use of the internalized group months, even years, later. We have considered, at several places in this text, how group members acquire skills that prepare them for new social situations in the future. Not only are extrinsic skills, such as greater emotional intelligence and empathic capacity, acquired, but intrinsic capacities are also released. Psychotherapy removes neurotic obstructions that have stunted the development of the client’s own resources. The view of therapy as obstruction removal lightens the burden of therapists and enables them to retain respect for the rich, never fully knowable, capacities of their clients. Individual Differences and Therapeutic Factors There is considerable individual variation in the rankings of therapeutic factors, and some researchers have attempted to determine the individual characteristics that influence these choices. There is evidence that level of functioning is significantly related to the ranking of therapeutic factors: for example, higher-functioning individuals with greater psychological-mindedness value interpersonal learning (the cluster of interpersonal input and output, catharsis, and self-understanding) more than the lower-functioning members in the same group do.118 It has also been shown that inpatient group members with less psychological awareness value the instillation of hope, whereas higher-functioning members in the same groups value universality, vicarious learning, and interpersonal learning.119 A large number of other studies demonstrate differences between individuals based on other differential criteria (high encounter group learners vs. low learners, dominant vs. nondominant clients, overly responsible vs. nonresponsible clients, high self-acceptors vs. low self-acceptors, high-affiliative vs. low-affiliative students).120 Not everyone needs the same things or responds in the same way to group therapy. Attachment style is a source of much divergence. Insecure and anxiously attached individuals will draw comfort from the sense of belonging in a group and use that as a platform for therapy and developing more secure attachment. In contrast, clients with a dismissive and avoidant attachment style may experience the same group degree of cohesiveness as intrusive and demanding, even aversive.121 They disclose little and are less engaged with other members. Yet if they are supported and persevere, they eventually engage and show significant and durable improvements in attachment security, mood, and interpersonal functioning.122 Clients with a secure attachment style readily make excellent use of cohesion and dive in with self-disclosures and openness to feedback.123 As always in our work, the relationally rich get richer. The challenge is helping the relationally poor get richer. There are many therapeutic pathways through the group therapy experience. Consider, for example, catharsis. Some restricted individuals benefit by experiencing and expressing strong affect, whereas others, who have problems of impulse control and great emotional lability, may not benefit from catharsis but instead from reining in emotional expression and acquiring intellectual structure. Narcissistic individuals need to learn to share and to give, whereas passive, self-effacing individuals need to learn to express their needs and to become more self-focused. Some clients may need to develop even rudimentary social skills; others may need to work with more complex issues—for example, a male client who needs to stop competing with all the members of the group, demonstrating his superior intellect at the expense of any warmth or closeness with others. In sum, the comparative potency of the therapeutic factors is complex. Different factors are valued by different types of therapy groups, by the same group at different developmental stages, and by different clients within the same group, depending on individual needs and strengths. We also see that the power of the interactional outpatient group emanates from its interpersonal focus. Interpersonal interaction, exploration (encompassing catharsis and self-understanding), and group cohesiveness are the sine qua non of effective group therapy, and effective group therapists must direct their efforts toward maximizing these therapeutic forces. We now turn our attention to the role and the techniques of the group therapist from the viewpoint of these therapeutic factors. Later chapters will address the group therapist’s role and techniques in specialized groups and settings. Footnotes i The list of sixty factor items passed through several versions and was circulated among senior group therapists for suggestions, additions, and deletions. Some of the items are nearly identical, but it was necessary methodologically to have the same number of items representing each category. The twelve categories are altruism, group cohesiveness, universality, interpersonal learning—input, interpersonal learning—output, guidance, catharsis, identification, family reenactment, self-understanding, instillation of hope, and existential factors. They are not quite identical to those described in this book; we attempted, unsuccessfully, to divide interpersonal learning into two parts: input and output. One category, self-understanding, was included to permit examination of derepression and insight regarding the early life contributions to current psychological difficulties. Imparting information replaces guidance. Corrective recapitulation of the primary family group replaces family reenactment. Development of socializing techniques replaces interpersonal learning—output. Interpersonal learning replaces Interpersonal learning—input and self-understanding. Finally, imitative behavior replaces identification. The therapeutic factor survey was meant to be an exploratory instrument constructed a priori on the basis of clinical intuition (my own and that of experienced clinicians); it was never meant to be posited as a finely calibrated research instrument. But it has been used in so much subsequent research that much discussion has arisen about construct validity and test-retest reliability. Multilevel statistical analysis may further refine our understanding beyond descriptive analysis. In a series of papers, Dennis Kivlighan and colleagues noted that clear patterns of therapeutic factor rankings across groups do not readily emerge; they categorized therapeutic factors according to the type of group studied and distinguished between affective insight, affective support, cognitive insight, and cognitive support groups. Giorgio Tasca and colleagues realigned the therapeutic factors into four overarching ones: social learning, secure emotional expression, instillation of hope, and awareness of relational impact. This classification shows good internal consistency and predictive value for outcome. Mark Stone, Carol Lewis, and Ariadne Beck have also constructed a brief, modified form with considerable internal consistency. iii In considering these results, we must keep in mind that the subject’s task was a forced sort, which means that the lowest-ranked items are not necessarily unimportant but are simply less important than the others. Each item carries some therapeutic potency. ix Factor analysis is a statistical method that identifies the smallest number of hypothetical constructs needed to explain the greatest degree of consistency in a data set. It is a way to compress large quantities of data into smaller but conceptually and practically consistent data groupings. Chapter 5 The Therapist Basic Tasks NOW THAT WE HAVE CONSIDERED HOW PEOPLE CHANGE IN group therapy, it is time to turn to the therapist’s role in the therapeutic process. In this chapter, we consider the basic tasks of the therapist and the techniques by which they may be accomplished. The four previous chapters contended that therapy is a complex process consisting of elemental factors that interlace in an intricate fashion. The group therapist’s job is to create the machinery of therapy, to set it in motion, and to keep it operating with maximum effectiveness. These tasks require different types of knowledge and skills but build atop a consistent therapeutic attitude and approach that we will return to again and again. Underlying all considerations of technique must be a consistent, positive, empathic, and culturally attuned relationship between therapist and client. The basic posture of the therapist to a client must be one of concern, genuineness, empathy, and emotional engagement. Nothing, no technical consideration, takes precedence over this attitude. Of course, there will be times when the therapist challenges the client, shows frustration, even suggests that if the client is not going to work, he or she should consider leaving the group. But these efforts (which in the right circumstances may have therapeutic clout) are never effective unless they are experienced against a horizon of an accepting and caring therapist-client relationship. Research consistently demonstrates that all effective psychotherapists share these common features.1 We will discuss the techniques of the therapist in respect to three fundamental tasks: 1. Creation and maintenance of the group 2. Building a group culture 3. Activation and illumination of the here-and-now CREATION AND MAINTENANCE OF THE GROUP Group leaders are solely responsible for creating and convening the group and setting the time and place for meetings. Much of their work is performed before the first meeting, and, as we will elaborate in later chapters, their expertise in the selection and preparation of members in composing the group will greatly influence the group’s fate. In agency and institutional settings, an additional consideration includes their relationship with the administration whose practical support is essential in creating and sustaining successful therapy groups.2 Once the group begins, the therapist attends to gatekeeping, especially the prevention of member attrition. Clients who complete the anticipated course of therapy generally improve significantly. The challenge is keeping them in treatment.3 Occasionally an individual will have an unsuccessful group experience and leave therapy prematurely. Yet such an experience may play some useful function in his or her overall course of therapy; failure in or rejection by a group may so unsettle clients as to prime them ideally for subsequent treatment. For example, in my role as the clinical supervisor and coordinator of trainee-led group therapy, I (ML) received an email from Amy, a client who had angrily dropped out of her first group experience and then attended and completed another therapy group: “Thank you for giving me a second chance with group therapy to work through my stuff. My second experience could not have been more different from the first group—I am sure I learned some things about myself after the first fiasco but I must tell you that the members of the 2nd group and I were a much better fit and the group leaders in my second group were so caring that I felt safe to open up for the first time.” Amy’s email powerfully reminds us to be open to therapy second chances. Generally, however, a client who drops out early in the course of the group should be considered a therapeutic failure. Not only does the client fail to receive benefit, but the progress of the remainder of the group is adversely affected. Stability of membership is an absolutely essential condition for successful therapy. If dropouts do occur, the therapist must, except in the case of a closed group (see Chapter 9), add new members to maintain the group at its ideal size. Initially, the clients are strangers to one another and know only the therapist, who is the group’s primary unifying force. The members relate to one another at first through their common relationship with the therapist, and these therapist-client alliances set the stage for the eventual development of group cohesion. The therapist must recognize and deter any forces that threaten group cohesiveness. Continued lateness, absences, the formation of subgroups, disruptive extragroup socialization, and scapegoating all threaten the functional integrity of the group and require therapist intervention. Each of these issues will be discussed fully in later chapters. For now, it is necessary only to emphasize the therapist’s responsibility to supra-individual needs. Your first developmental task is to help create and maintain a physical entity: a cohesive group. There will be times when you must delay dealing with the pressing needs of an individual client, and even times when you will have to remove a member from the group for the good of the other members. A clinical vignette illustrates some of these points: > I (IY) introduced two new members, both women, into an outpatient group. This particular group, with a stable core of five men and two women, had difficulty retaining female members. Two women had dropped out in the previous month. This meeting began inauspiciously for one of the new members when her perfume triggered a sneezing fit in one of the men, who moved his chair away from her and then, while vigorously opening the windows, informed her of his perfume allergy and of the group’s “no scent” rule.
At this point another member, Mitch, arrived a couple of minutes late and, without even a glance at the two new members, announced, “I need some time today from the group. I was really shaken up by the meeting last week. I went home from the group very disturbed by the feedback about my being a time hog. I didn’t like those comments from any of you, or from you [meaning me] either. It threw me off completely and later that evening I had an enormous fight with my wife, who took exception to my reading my iPad at the dinner table, and we haven’t been speaking since.”
Now this particular opening would have been a good one for most group meetings. It had many things going for it. The client stated that he wanted some time. (The more members who come to the group asking for time and eager to work, the more energized a meeting will be.) Also, he wanted to work on issues that had been raised in the previous week’s meeting. (As a general rule, the more group members work on continuing themes from meeting to meeting, the more effective the group becomes.) Furthermore, he began the meeting by attacking me, the therapist, and that was a good thing; this group had been treating me much too gently. Mitch’s attack, though uncomfortable, was, I felt certain, going to produce important group work.
I had many different options in the meeting, but one task had highest priority: maintaining the functional integrity of the group. I had introduced two female members into a group that had had some difficulty retaining women. And how had the members of the group responded? Not well! They had virtually disenfranchised the new members. After the sneezing incident, Mitch had not even acknowledged their presence and had launched into a discussion of his marriage—a subject that, though personally important, inherently excluded the new women by referring to the previous meeting.
It was important, then, for me to find a way to address this task and, if possible, also to address the issues Mitch had raised. Earlier in this book I offered the basic principle that therapy should strive to turn all issues into here-and-now issues. It would have been folly to deal explicitly with Mitch’s fight with his wife. The data that Mitch would have given about his wife would have been biased and he might well have “yes, but-ted” the group into submission.
Fortunately, however, there was a way to tackle both issues at once. Mitch’s treatment of the two women in the group bore many similarities to his treatment of his wife at the dinner table. He had been as insensitive to their presence and needs as to his wife’s. In fact, it was precisely his insensitivity that the group had confronted the previous meeting.
Therefore, about a half hour into the meeting, I pried the group’s focus away from Mitch and his wife by saying, “Mitch, I wonder what hunches you have about how our two new members are feeling in the group today?”
This inquiry led Mitch into the general issue of empathy and his inability or unwillingness in many situations to enter the experiential world of the other. Fortunately, this tactic not only turned the other group members’ attention to the way they all had ignored the two new women, but also helped Mitch work effectively on his core problem: his failure to recognize and appreciate the needs and wishes of others. Even if it were not possible to address some of Mitch’s central issues around empathy and his self-absorption, I still would have opted to attend to the integration of the new members. The integration of new members and the physical survival of the group takes precedence over other tasks. << BUILDING A GROUP Once the group is a physical reality, the therapist’s energy must be directed toward shaping it into a therapeutic social system. An unwritten code of behavioral rules, or norms, must be established that will guide the interaction of the group. And what are the desirable norms for a therapeutic group? They follow logically from the discussion of the therapeutic factors. Consider for a moment the therapeutic factors outlined in the first four chapters: acceptance and support, universality, advice, interpersonal learning, altruism, and hope. Who provides these? Obviously, the other members of the group! Thus, to a large extent, it is the group and group members that are the agents of change. Herein lies a crucial difference in the basic roles of the individual therapist and the group therapist. In the individual format, the therapist functions as the solely designated direct agent of change. The group therapist functions far more indirectly. In other words, if it is the group members who, in their interaction, set into motion the many therapeutic factors, then it is the group therapist’s task to create a group culture maximally conducive to effective group interaction. A jazz pianist, and group member, once commented on the role of the leader by reflecting that very early in his musical career, he deeply admired the great instrumental virtuosos. It was only much later that he grew to understand that the truly great jazz musicians were those who knew how to augment the sound of others, how to be quiet, how to enhance the functioning of the entire ensemble. European group analysts even refer to the group leader as the conductor.4 It is obvious that the therapy group has norms that radically depart from the rules, or etiquette, of typical social intercourse. Unlike almost any other kind of group, the members must feel free to comment on the immediate feelings they experience toward the group, the other members, and the therapist. Honesty and spontaneity of expression must be encouraged in the group. If the group is to develop into a true social microcosm, members must interact freely with one another and not funnel their comments through the group leader. Other desirable norms include active involvement in the group, nonjudgmental acceptance of others, honoring and protecting the group’s work, extensive self-disclosure, desire for self-understanding, and an eagerness to change current modes of behavior. Norms may be a prescription for as well as a proscription against certain types of behavior. Strong client and therapist alignment about therapy expectations is a significant predictor of good outcome.5 Norms may be implicit as well as explicit. In fact, the members of a group cannot generally generally consciously articulate the norms of the group. Researchers studying norms might best be advised to present the members with a list of behaviors and ask them to indicate which are appropriate and which inappropriate in the group. Norms invariably evolve in every type of group—social, professional, and therapeutic.6 By no means is it inevitable that a therapeutic group will evolve norms that facilitate the therapeutic process. Systematic observation reveals that many therapy groups are encumbered with crippling norms. A group may, for example, so value hostile catharsis that positive sentiments are eschewed; conversely, a group may become so afraid of causing injury that no conflict is permitted, and the group becomes stagnant. A group may develop a “take turns” format in which the members sequentially describe their problems; or a group may have norms that do not permit members to question or challenge the therapist. Ready acceptance of group member absences will erode the attendance of even the most committed clients.7 Shortly we will discuss some specific norms that hamper or facilitate therapy, but first we will consider how norms come into being. The Construction of Norms Norms of a group are constructed both from expectations of the members for their group and from the explicit and implicit directions of the leader and more influential members. In institutional settings group norms are also shaped by the larger unit’s or organization’s culture.8 If the members’ expectations are not fully formed, then the leader has even more opportunity to shape a group culture that, in his or her view, will be optimally therapeutic. The group leader’s comments in the meetings play a powerful, though usually implicit, role in determining group norms. In one study, researchers observed that when the leader made a comment following closely after a particular member’s actions, that member became a center of attention in the group and often assumed a major role in future meetings. Furthermore, the relative infrequency of the leaders’ comments augmented the strength of their interventions.9 In general, leaders who set norms of increased engagement and decreased conflict have better clinical outcomes.10 By discussing the leader as norm-shaper, we are not proposing a new or contrived role for the therapist. Wittingly or unwittingly, leaders always shape the norms of the group and must be aware of this function. I (ML) had a yearlong, unavoidable, once a month commitment to chair an important hospital committee meeting, the ending of which conflicted with the start of my ongoing group. Once monthly, with great chagrin, I would arrive to the group ten to fifteen minutes late. It was ably led by my co-therapist, and the group started on time, but punctuality in the group that year was consistently poor. Despite my apologies and processing of my unavoidable lateness, the group’s punctuality was restored only after I concluded my competing duties and could realign my own behavior with our expressed norm. Just as one cannot not communicate, the leader cannot not influence norms; virtually all of his or her early group behavior is influential. Moreover, what one does not do is often as important as what one does do. Once I (IY) observed a group led by a group analyst in which a member who had been absent the six previous meetings entered the meeting a few minutes late. The therapist in no way acknowledged the arrival of the member; after the session, he explained to the student observers that he chose not to influence the group, since he preferred that the members make their own rules about welcoming tardy or prodigal members. It appeared clear to me, however, that the therapist’s non-welcome was an influential act and very much of a norm-setting message. His group had evolved, no doubt as a result of many similar previous actions, into an uncaring, insecure one whose members sought methods of currying the leader’s favor. To summarize: Every group evolves a set of unwritten rules or norms that determine the course of the group. The ideal therapy group has norms that permit the therapeutic factors to operate with maximum effectiveness. Norms are shaped both by the expectations of the group members and by the behavior of the therapist. The institutional setting also plays a norm-shaping role. Therapists are enormously influential in setting norms; in fact, they cannot avoid doing so. Norms constructed early in the group have considerable perseverance. The therapist is thus well advised to go about this important function in an informed, deliberate manner. HOW DOES THE LEADER SHAPE NORMS? There are two basic roles the therapist may assume in a group: technical expert and model-setting participant. In each of these roles, the therapist helps to shape the norms of the group. The Technical Expert When assuming the role of technical expert, therapists deliberately slip into the traditional garb of expert and employ a variety of techniques to move the group in a direction they consider desirable. They explicitly attempt to shape norms during their early preparation of clients for group therapy. In this procedure, described fully in Chapter 10, therapists carefully instruct clients about the rules of the group, and they reinforce the instruction in two ways: first, by backing it with the weight of authority and experience; and second, by explaining the rationale for the group approach and tying it directly to the clients’ goals. At the beginning of a group, therapists have at their disposal a wide choice of techniques to shape the group culture. These range from explicit instructions and suggestions to subtle reinforcing techniques. For example, as we described earlier, the leader must attempt to create a network in which the members freely interact with each other rather than directing all their comments to or through the therapist. To this end, therapists may implicitly instruct members in their pregroup interviews or in the first group sessions; they may, repeatedly during the meetings, ask for all members’ reactions to another member or toward a group issue; they may ask why conversation is invariably directed toward the therapist; they may ask the group to engage in exercises that teach clients to interact—for example, asking each member of the group in turn to give his or her first impressions of every other member; or therapists may, in a much less obtrusive manner, shape behavior by rewarding members who address one another: by nodding or smiling at them, addressing them warmly, or shifting their posture into a more receptive position. Exactly the same approaches may be applied to the many other norms the therapist wishes to inculcate: self-disclosure, open expression of emotions, promptness, self-exploration, and so on. In early sessions particularly, the therapist can underscore the emerging group norms and seize natural opportunities to highlight and articulate these norms. This leads to a “smoother” group and is preferable to reading a laundry list of principles. Therapists vary considerably in style. Although many prefer to shape norms explicitly, all therapists, to a degree often greater than they suppose, perform their tasks through the subtle technique of social reinforcement. Advertising and social media are two examples of a systematic harnessing of reinforcing agents whose impact far exceeds our conscious awareness. Psychotherapy, no less, relies on the use of subtle, often nondeliberate social reinforcers. Although few self-respecting therapists like to consider themselves social reinforcing agents, they nevertheless continuously exert influence in this manner, unconsciously or deliberately. They may positively reinforce behavior by means of numerous types of verbal and nonverbal acts, including nodding, smiling, leaning forward, or offering an interested “mmm” or a direct inquiry for more information. On the other hand, therapists attempt to extinguish behavior not deemed salubrious by not commenting, not nodding, ignoring the behavior, turning their attention to another client, looking skeptical, raising their eyebrows, and so on. In fact, research suggests that therapists who reinforce members’ pro-group behavior indirectly are often more effective than those who prompt such behavior explicitly.11 Every form of psychotherapy is a learning process, relying in part on operant conditioning. Therapy without some form of therapist reinforcement or manipulation is a mirage that disappears on close scrutiny.12 Considerable research demonstrates the efficacy of operant techniques in the shaping of group behavior.13 Using these techniques deliberately, one can reduce silences or increase the number of personal and group comments, expressions of hostility to the leader, or intermember acceptance.14 Though there is evidence that therapists owe much of their effectiveness to these learning principles, they often eschew this evidence because of their unfounded fear that such a mechanistic view will undermine the essential human component of the therapy experience. The facts are compelling, however, and an understanding of their own behavior does not strip therapists of their spontaneity. After all, the objective of using operant techniques is to foster authentic and meaningful engagement. Our clients can distinguish our facilitation from manipulation.15 The Model-Setting Participant Leaders shape group norms not only through explicit or implicit social engineering but also through the example they set in their own group behavior.16 The therapy group culture represents a radical departure from the social rules to which clients are accustomed. Clients are asked to discard familiar social conventions, to try out new behavior, and to take many risks. How can therapists best demonstrate to their clients that new behavior will not have the anticipated adverse consequences? One method, which has considerable research backing, is modeling: clients are encouraged to alter their behavior by observing their therapists engaging freely and without adverse effects from the desired behavior.17 Albert Bandura, a prominent psychologist, has demonstrated in many well-controlled studies that individuals may be influenced to engage in more adaptive behavior (for example, the overcoming of specific phobias) or less adaptive behavior (for example, unrestrained aggressivity) through observing and adopting others’ behavior.18 The public nature of group therapy makes the dynamics of shame or humiliation particularly powerful for all, and group leaders’ humility and courage in addressing their own therapeutic errors and missteps demonstrate humanity and compassion.19 It can be remarkably helpful to say something like, “I have been thinking a lot about the last meeting. I wish I understood then what I understand now. I would have approached this differently. I welcome the opportunity to revisit this with you.” The leader may, by offering a model of nonjudgmental acceptance and appreciation of others’ strengths as well as their problem areas, help shape a group that is health oriented. If leaders conceptualize their role as that of a detective of psychopathology, the group members will follow suit. For example, one group member had actively worked on the problems of other members for months but had steadfastly declined to disclose her own problems. Finally, in one meeting she confessed that one year earlier she had had a two-month stay in a state psychiatric hospital. The therapist responded reflexively, “Why haven’t you told us this before?” This comment, emerging from the therapist’s irritation, was perceived as punitive by the client and served only to reinforce her fear and discourage further self-disclosure. Obviously, there are questions and comments that will close people down and others that will help them open up. The therapist had many “opening-up” options: for example, “I think it’s great that you now trust the group sufficiently to share these facts about yourself. How difficult it must have been for you in the group previously, wanting to share this disclosure and yet being afraid to do so”; “What is it like to bring this up now?”; or, “How did you determine that you would share this with us tonight?” The leader sets a model of interpersonal honesty and spontaneity but must also keep the current needs of the members in mind and demonstrate behavior that is congruent with those needs. We do not suggest that group therapists should freely express all feelings. Total disinhibition is no more helpful in therapy groups than in other forms of human encounter and may lead to ugly, destructive interaction. Although we encourage spontaneity, generally it is wise for a therapist to model appropriate restraint as well as honesty.20 Not only is it therapeutic to our clients that we let them matter to us, but we can also use our own reactions as valuable data about our clients—provided we know ourselves well enough. We want to engage our clients and allow ourselves to be affected by them. Our “disciplined personal involvement” is an invaluable part of the group leader’s armamentarium.21 Consider the following therapeutically effective intervention: > In the first session of a group of business executives meeting for a five-day intensive communication training program that I (IY) was co-leading, an aggressive, swaggering twenty-five-year-old group member who had obviously been drinking heavily proceeded to dominate the meeting and make a fool of himself. He boasted of his accomplishments, belittled the group, monopolized the meeting, and interrupted, outshouted, and insulted every other member. All attempts to deal with the situation—feedback about how angry or hurt he had made others feel, interpretations about the meaning and cause of his behavior—failed. Then my co-leader commented sincerely, “You know what I like about you? Your fear and lack of confidence. You’re scared here, just like me. We’re all scared about what will happen to us this week.” That statement permitted the client to discard his facade and, eventually, to become a valuable group member. Furthermore, the leader, by modeling an empathic, nonjudgmental style, helped establish a gentle, accepting group culture. << This effective intervention required that the co-leader first recognize the negative impact of this member’s behavior and work with her own initial hostility and countertransference; only then could she supportively articulate the vulnerability that lay beneath the client’s offensive behavior.22 We aim to be both honest and compassionate in understanding our members’ best (if ineffective) adaptive efforts. This, in turn, contributes to group cohesiveness as others begin to experience the group as a safe place where forthrightness is valued.23 How can we expect our clients to be braver than we are? Our group interaction demands—among other things—that group therapists accept and admit their personal fallibility. A group member in a beginning group accused a neophyte group therapist of making long-winded, confusing statements. Since this was the first confrontation of the therapist in this young group, the members were tense and perched on the edge of their chairs. The therapist responded by wondering whether he didn’t remind the client of someone from the past. The attacking member clutched at the suggestion and volunteered his father as a candidate; the crisis passed, and the group members settled back in their chairs. However, it so happened that this therapist had himself previously been a member of a process group for trainees, and his colleagues had repeatedly focused on his tendency to make long-winded, confusing comments. In fact, then, what had transpired was that the client had seen the therapist quite correctly but was persuaded to relinquish his perceptions. If one of the goals of therapy is to help clients test reality and clarify their interpersonal relationships, then this transaction was antitherapeutic. This is an instance in which the therapist’s needs were given precedence over the client’s needs. In psychotherapy we must never damage our clients by protecting our own interests.24 Another consequence of the need to be perfect occurs when therapists become overly cautious. Fearing error, they weigh their words so carefully, interact so deliberately, that they sacrifice spontaneity and mold a stilted, lifeless group. Often a therapist who maintains an omnipotent, distant role is saying, in effect, “Do what you will; you can’t hurt or touch me.” This pose may have the counterproductive effect of stifling the collaborative nature of group therapy and aggravating a sense of interpersonal impotence in clients that impedes the development of an autonomous group. > In one group, Les, a young man, had made little movement for months despite vigorous efforts by the leader. In virtually every meeting the leader attempted to bring Les into the discussion, but to no avail. Instead, Les became more defiant and withholding, and the therapist became more active and insistent. Finally, Joan, another member, commented to the therapist that he was like a stubborn father treating Les like a stubborn son, and was bound and determined to make Les change. Les, she added, was relishing the role of the rebellious son who was determined to defeat his father. Joan’s comment rang true for the therapist; it clicked with his internal experience, and he acknowledged this to the group and thanked Joan for her comments. << The therapist’s behavior in this example was extremely important for the group. In effect, he said, “I value you group members, this group, and this mode of learning.” Furthermore, he reinforced norms of self-exploration and honest interaction with the therapist. The transaction was doubly helpful—to the therapist (unfortunate are the therapists who cannot learn more about themselves in their therapeutic work) and to Les, who proceeded to explore the payoff in his defiant stance toward the therapist. Occasionally, less modeling is required of the therapist because of the presence of some ideal group members who fulfill this function. Early studies even used “confederates”—people trained in collaboration with the group leaders as ideal group members, who were planted in groups to pose as actual members. They were clearly impactful regarding group cohesion and group work, though such tactics are not ethical by today’s standards.25 Although a trained “plant” would contribute a form of deceit incompatible with the process of group therapy, the concept has intriguing clinical implications regarding group composition and placement of prospective group members. For example, an individual who recently completed a time-limited group therapy satisfactorily and seeks further treatment might serve as a model-setting veteran member for a new group. Perhaps an ongoing group might choose to add new members in advance of the graduation of senior members, rather than afterward, to capitalize on the modeling provided by the experienced and successful senior members. These possibilities aside, it is the therapist who, wittingly or unwittingly, will continue to serve as the chief model-setting figure for the group members. Consequently, it is of the utmost importance that therapists have sufficient self-confidence and self-awareness to fulfill this function. If not, they will be more likely to encounter difficulties in this aspect of their role and will often veer to one extreme or the other in their personal engagement in the group: either they will fall back into a comfortable, concealed professional role, or they will escape from the anxiety and responsibility inherent in the leader’s role by abdicating and becoming simply one of the gang.26 Novice therapists are particularly prone to these positions of exaggerated activity or inactivity in the face of the emotional demands of leading therapy groups. Either extreme has unfortunate consequences for the development of group norms. An overly opaque and detached leader will create norms of caution and guardedness. A therapist who retreats from his requisite authority and purports to be a member will be unable to use the wide range of methods available for the shaping of constructive norms; furthermore, such a therapist creates a group that is unlikely to work fruitfully on important transference issues. The issue of the therapist’s transparency has implications far beyond the task of norm setting. When therapists are self-disclosing in the group, not only do they model behavior, but they perform an act that has considerable significance in many other ways for the therapeutic process. Many clients develop conflicted and distorted feelings toward the therapist; the transparency of the therapist helps members work through their transference. We shall discuss the ramifications of therapist transparency in great detail in Chapter 7. Let us turn now from this general discussion of norms to the specific norms that enhance the power of group therapy. THERAPEUTIC GROUP NORMS The Self-Monitoring Group It is important that the group begin to assume responsibility for its own functioning. If this norm fails to develop, a passive group ensues whose members are dependent on the leader to supply movement and direction. The leader of such a group who feels fatigued and irritated by the burden of making everything work is aware that something has gone awry in the early development of the group. When we lead groups like this, we often experience the members of the group as moviegoers. It’s as though they visit the group each week to see what’s playing; if it happens to interest them, they become engaged in the meeting. If not, “Too bad! Hope there’ll be a better show next week!” The therapist’s task in the group then is to help members understand that they are the movie. If they do not perform, there is no performance; the screen is blank. From the very beginning, we attempt to transfer the responsibility of the group to the members. We keep in mind that, in the beginning of a group, we are the only members in the room who have a good definition of what constitutes a good work meeting, and it is our task to teach the members and share that definition with them. Thus, if the group has a particularly good meeting, label it so. For example, you might comment at the end, “It’s time to stop. It’s too bad, I hate to bring a meeting like this to an end.” In future meetings, we often make a point of referring back to that meeting. It becomes a benchmark. In a young group, a particularly hardworking meeting is often followed by a meeting in which the members step back a bit from the intensive interaction. In such a meeting, you might comment, after a half hour, “I wonder how everyone feels about the meeting today? How would you compare it with last week’s meeting? What did we do differently last week?” It is also possible to help members develop a definition of a good meeting by asking them to examine and evaluate parts of a single meeting. For example, in the very early meetings of a group, you may jump in with a process reflection: “I see that an hour has gone by and I’d like to ask, ‘How has the group gone today? Are you satisfied with it? What’s been the most engaging part of the meeting so far today? The least engaging part?’” The general point is clear: endeavor to shift the evaluative function from yourself to the group members, in effect saying, “You have the ability—and responsibility—to determine when this group is working effectively and when it is wasting its time.” Best yet is when a group member comments that this was a great meeting. This is a golden invitation to examine what made it a great meeting and deconstruct the meeting into its key components—risk-taking, deepening closeness, inspiration, support, feeling valued, disconfirming shame—so that the members can reliably be engaged again and again. This will not happen without the group leader’s initiative in launching the process. If a member laments, for example, that “the only involving part of this meeting was the first ten minutes —after that we’ve just chatted for forty-five minutes,” it begs the response: “Then why did you let it go on? How could you have stopped it?” Or, “All of you seemed to have known this. What prevented you from acting?” Soon there will be excellent consensus about what is productive and unproductive group work. (And it will generally be the case that productive work occurs when the group maintains a here-and-now focus—which we will discuss in the next chapter.) Self-Disclosure Group therapists may disagree about many aspects of the group therapeutic procedure, but there is great consensus about one issue: Client self-disclosure is absolutely essential in the group therapeutic process. Group members will not benefit from group therapy unless they commit to self-disclose. We prefer to lead a group with norms that indicate that self-disclosure must occur—but at each member’s own pace: it’s important that members not experience the group as a forced confessional where deep revelations are wrung from members one by one.27 During pregroup individual meetings, we make these points explicit to clients so that they enter the group fully informed that if they are to benefit from therapy, sooner or later they must share very intimate parts of themselves with the other group members. Keep in mind that it is the subjective aspect of self-disclosure that is truly important. There may be times when therapists or group observers will mistakenly conclude that the group is not truly disclosing or that the disclosure is superficial or trivial. Many group therapy members have had few intimate confidants, and what appears in the group to be a minor self-disclosure may represent the very first time a member has shared the material with anyone. Appreciating the context of each individual’s disclosure is a crucial part of mentalizing about others and developing empathy. > One group member, Mark, spoke slowly and methodically about his intense social anxiety and avoidance. Marie, a, chronically depressed and bitter young woman, bristled at his long and labored elaboration of his difficulties. At one point she wondered aloud why others seemed to be so encouraging of Mark and excited about his speaking, whereas she felt so impatient with the slow pace of the group. She was concerned that she could not get to her personal agenda: to learn to make herself more likable. The feedback she received surprised her. Many members felt alienated from her because she rarely empathized with others. What was happening in the meeting with Mark was a case in point, they told her. For many members Mark’s self-disclosure in the meeting was a great step forward for him. What interfered with her seeing what others saw? That was the critical question, and exploring that question ultimately led to important learning for Marie. << What about the big secret? Members may come to therapy with important secrets about some central aspect of their lives—for example, promiscuity, transgender identity, substance abuse, criminality, bulimia, incest. They feel trapped. Though they wish to work in the therapy group, they are too frightened to share such secrets with a large group of people. In pregroup individual sessions, we make it clear to such clients that sooner or later they will have to share their secrets with the other group members. We emphasize that they may do this at their own pace, that they may choose to wait until they feel greater trust in the group, but that, ultimately, the sharing must come if therapy is to proceed. Group members who decide not to share a big secret are destined merely to re-create in the group the same duplicitous modes of relating to others that exist outside the group. To keep the secret hidden, they must guard every possible avenue that might lead to it. Hence, they are vigilant and guarded, and spin an ever-expanding web of inhibition around themselves. Sometimes the subjective meaning of a secret is not easily understood at first. > Vijay, a forty-two-year-old police officer, sought group therapy after an episode of domestic violence. He felt enormous shame about his behavior and realized he did not know how to deal with strong emotion. He was spared criminal proceedings on the condition he participate in group and individual therapy. Although willing to tell the group about the violence, he refused to tell the group about his occupation, despite members’ mounting curiosity and rampant guessing. For months, he denied its relevance and was firm and fixed in maintaining this secret. I (ML) knew about his profession but felt I had no choice but to wait for him to share this information. He was otherwise clearly engaged with the group and working on emotional recognition and self-expression.
After a short leave to attend his grandmother’s funeral in India, his birthplace, he returned to the group and declared, “I want to shed my remaining secrets—I am a police officer and I have behaved dishonorably. Going home for the funeral made me realize how destructive it can be to keep secrets. I had been estranged from my parents for years because of my father’s physical abuse, but I had been very close to his mother as a boy. Visiting back home I learned for the first time that my grandmother was Muslim and that even her name was shunned in my family’s Hindu village.
“My grandmother’s religion was a deeply shameful and lethally dangerous secret. No one ever spoke of it. I also learned for the first time that, because of his mother’s religion, my father was discriminated against and bullied mercilessly as a child. Learning these things was eye-opening, and I felt, for the first time in my life, compassion for my father. I understood how the brutality my father experienced contributed to his becoming a brutal father and husband. I see now that shutting down many areas of my own world and silencing myself has made me abusive as well.”
He became quite emotional in the meeting, and the group members—many of whom had already suspected he was a police officer—helped him look at this as an unlocking from the various cul-de-sacs in his emotional world. At the end of the session, the group told him they felt incredibly close to him and were honored by his trust. << Sometimes it is adaptive to delay the telling of the secret. Consider the following two group members, John and Charles. John had been cross-dressing since the age of twelve. This was something he did frequently but secretly. Charles entered the group with cancer. He stated that he had done a lot of work learning to cope with his cancer. He knew his prognosis: he would live for two or three more years. He had sought group therapy in order to live his remaining life more fully, and he especially wanted to relate more intimately with the important people in his life. This seemed like a legitimate goal for group therapy, and I (IY) introduced him into a regular outpatient therapy group. (I have fully described this individual’s course of treatment elsewhere.)28 Each client had told me his secret but chose not to disclose it in the group for many sessions. By that time, I was getting edgy and impatient. I gave them knowing glances or subtle invitations. Eventually each became fully integrated into the group, developed a deep trust in the other members, and, after about a dozen meetings, chose to reveal very fully. In retrospect, both of their decisions to delay were wise ones. The group members had grown to know them as people, as John and Charles, who were faced with major life problems, not as a cross-dresser and a cancer patient. John and Charles had been justifiably concerned that if they revealed themselves too early, they would be stereotyped, and that the stereotype would block other members from knowing them fully. How can the group leader determine whether a client’s delay in disclosure is appropriate or countertherapeutic? Context matters. Even without full disclosure, is there, nonetheless, movement, albeit slow, toward increasing openness and trust? Will the passage of time make it easier to disclose, as happened with John and Charles, or will tension and avoidance mount? Rarely is a high-risk self-disclosure met with frank rejection. There is usually some therapeutic leverage that protects against this happening. The serial cheater wants to own his infidelity and build intimacy with his current wife; the disbarred lawyer wants to rehabilitate himself and repay those he defrauded; the IV drug user is terrified of dying and life now has become more worth living. If a client is shamed and wholly rejected by the group after a difficult disclosure, the therapist must examine whether he or she is colluding with the group members’ attack because of his or her own reaction or countertransference. If that is the case, it is doubly incumbent upon the group leaders to initiate the repair process as quickly as possible. Often, hanging onto the big secret for too long is counterproductive. Consider the following example: > Lisa, a client in a six-month, time-limited group, had practiced as a psychologist for a few years, but had given up her practice fifteen years earlier to enter the business world, where she soon became extraordinarily successful. She entered the group because of dissatisfaction with her social life. Lisa felt lonely and alienated. She knew that she, as she put it, played her cards “too close to the vest”—she was cordial to others and a good listener but tended to remain distant. She attributed this to her enormous wealth, which she felt she must keep concealed so as not to elicit envy and resentment from others.
By the fifth month, Lisa had yet to reveal much of herself. She retained her psychotherapeutic skills, and this proved helpful to many members, who admired her greatly for her unusual perceptiveness and sensitivity. But she had replicated her outside social relationships in the group, and she felt hidden and distant from the other members. She requested an individual session with the group leader to discuss her participation in the group. During that session the therapist exhorted Lisa to reveal her concerns about her wealth and, especially, her psychotherapy training, warning her that if she waited too much longer, someone would throw a chair at her when she finally told the group she had once been a therapist. Finally, Lisa took the plunge and in the very few remaining meetings did more therapeutic work than in all the earlier meetings combined. <<
What stance should the therapist take when someone reveals the big secret? To answer that question, we must first make an important distinction. We believe that when an individual reveals the big secret, the therapist must help him or her disclose even more about the secret, but in a horizontal rather than a vertical mode. By vertical disclosure we refer to content, to greater in-depth disclosure about the secret itself. For example, when John disclosed his cross-dressing to the group, the members’ natural inclination was to explore the secret in vertical detail. They asked about details of his cross-dressing: “How old were you when you started?” “Whose underclothes did you begin to wear?” “What sexual fantasies do you have when you cross-dress?” “How do you publicly pass as a woman with that facial hair?” But John had already disclosed a great deal of detail about his secret, and it was more important for him now to engage in horizontal disclosure, i.e., how he felt about disclosing the secret to the group members:
Accordingly, when John first divulged his cross-dressing in the group, I (IY) asked questions that would lead to horizontal disclosure:
• “John, you’ve been coming to the group for approximately twelve meetings and have not been able to share this with us. I wonder what it’s been like for you to come each week and remain silent about your secret?”
• “How uncomfortable have you been about the prospect of sharing this with us? It hasn’t felt safe for you to share this before now. Today you chose to do so. What’s happened in the group or in your feelings toward the group today that’s allowed you to do this?”
• “What were your fears in the past about revealing this to us? What did you think would happen? Whom did you feel would respond in which ways?”
These are part of a host of here-and-now reflection questions that move from the content of the disclosure to the interactional aspects of the disclosure.
John responded that he feared he would be ridiculed or laughed at or thought weird. In keeping with the here-and-now inquiry, I guided him deeper into the interpersonal process by inquiring, “Who in the group would ridicule you?” “Who would think you were weird?” And then, after John selected certain members, I invited him to check out those assumptions with them. By welcoming the belated disclosure, rather than criticizing the delay, the therapist supports the client and strengthens the therapeutic collaboration. As a general rule, it is always helpful to move from general statements about the “group” to more personal statements: in other words, ask members to differentiate between the members of the group.
Self-disclosure is always an interpersonal act. What is important is not that one discloses oneself but that one discloses something important in the context of a relationship to others. The act of self-disclosure takes on real importance because of its implications for the nature of ongoing relationships; even more important than the actual unburdening of oneself is the fact that disclosure results in a deeper, richer, and more complex relationship with others.
The disclosure of sexual abuse or incest is particularly charged in relational terms. Often victims of such abuse have been traumatized not only by the abuse itself but also by the way others have responded to their disclosure of the abuse in the past. Not uncommonly, the initial disclosure within the victim’s family is met with denial, blame, and rejection. As a result, the thought of disclosing oneself in the therapy group evokes fear of further mistreatment and even retraumatization rather than hope of working through the abuse.29 This phenomenon is prevalent as well in organizational and educational settings. Frequently, the administrative blindness and denial that shames and faults the victim feels to that victim as traumatic and as much of a betrayal as the initial abuse.30
If undue pressure is placed on a member to disclose, we will, depending on the problems of the particular client and his or her stage of therapy, respond in one of several ways. For example, a therapist may relieve the pressure by commenting, “There are obviously some things that John doesn’t yet feel like sharing,” or, “The group seems eager, even impatient, to bring John aboard, while John doesn’t yet feel safe or comfortable enough.” (The word “yet” is important, since it conveys the appropriate expectational set.) We might proceed by suggesting that we examine the unsafe aspects of the group, not only from John’s perspective but from other members’ perspectives as well. We shift the emphasis of the group from wringing out disclosures to exploring the obstacles to disclosure. What generates the fear? What are the anticipated dreaded consequences? From whom in the group do members anticipate disapproval? But the client is the final arbiter of the when and what of disclosure. The group leader can exhort and cajole and request but cannot reveal information about the client from pregroup meetings or from concurrent therapy without the client’s permission.
No one should ever be punished for self-disclosure. One of the most destructive events that can occur in a group is for members to use personal, sensitive material that has been disclosed and entrusted to the group against one another in times of conflict. The therapist should intervene vigorously if this occurs. Not only is such behavior dirty fighting, but it undermines important group norms. This vigorous intervention can take many forms. In one way or another, the therapist must call attention to the violation of trust. Often, we will simply stop the action, interrupt the conflict, and point out that something very important has just happened in the group. We ask the offended member for his or her feelings about the incident, or ask others for theirs, or wonder whether others have had experiences that are difficult to reveal in the group. Any other work in the group is temporarily postponed. It is important to reinforce the norm that self-disclosure is not only important but safe. Only after the norm has been established should we turn to examine other aspects of the incident.
Procedural Norms
The optimal procedural format in therapy is that the group be unstructured, spontaneous, and freely interacting. But such a format never evolves naturally: much active culture shaping is required on the part of the therapist. There are many trends the therapist must counter. The natural tendency of a new group is to devote an entire meeting to each of the members in rotation. Often the first person to speak or the one who presents the most pressing life crisis that week obtains the group floor for the meeting. Some groups have enormous difficulty changing the focus from one member to another, because a procedural norm has somehow evolved whereby a change of topic is considered bad form, rude, or rejecting. Members may lapse into silence: they feel they dare not interrupt and ask for time for themselves, yet they refuse to keep the other member supplied with questions because they hope, silently, that he or she will soon stop talking.
These patterns hamper the development of a potent group and ultimately result in group frustration and discouragement. We prefer to deal with these antitherapeutic norms by calling attention to them and indicating that since the group has constructed them, it has the power to change them.
For example, a group leader might say, “I’ve been noticing that over the past few sessions the entire meeting has been devoted to only one person, often the first one who speaks that day, and also that others seem unwilling to interrupt and are, I believe, sitting silently on many important feelings. I wonder how this practice ever got started and whether or not we want to change it.” A comment of this nature may be liberating to the group. The therapist has not only given voice to something that everyone knows to be true but has also raised the possibility of other procedural options.
Some groups evolve a formal “check-in” format in which each member in turn gets the floor to discuss important events of the previous week or certain moments of great distress. Sometimes, especially with groups of highly dysfunctional, anxious members, such an initial structure is necessary and helps facilitate engagement. But, in our experience, such a formal structure in most groups generally encourages an inefficient, taking-turns, noninteractive, “then-and-there” meeting that severely restricts the scope of what can be worked with in the group and avoids such issues as feelings of entitlement, envy, and competitiveness. The check-in employs a “content” solution to address a “process” problem. We prefer a format in which distressed members may simply announce at the beginning, “I want some time today,” and the members and the therapist attempt, during the natural evolution of the session, to turn to each of those members.
Specialized groups, especially those with brief life spans, often require different procedural norms. Compromises must be made for the sake of efficient time management, and the leader must build in an explicit structure. We will discuss such modifications of technique in Chapter 15 but for now wish only to emphasize a general principle: the leader must attempt to structure the group in such a way as to instill the therapeutic norms we discuss in this chapter—support and confrontation, self-disclosure, self-monitoring, interaction, spontaneity, and the importance of the group members as the agents of help.
The Importance of the Group to Its Members
The more important the members consider the group to be, the more effective it becomes. We believe that the ideal therapeutic condition is present when clients consider their therapy group meeting to be one of the most important events in their lives each week and zealously protect the group time. The therapist is well advised to reinforce this belief in any available manner. If you are forced to miss a meeting, inform the members well in advance and convey to them your concern about your absence. Arrive punctually for meetings, and if you have been thinking about the group between sessions, share some of these thoughts with the members. Any self-disclosures you make should be made in the service of the group. Though some therapists eschew such personal disclosure, we believe that it is important to articulate how much the group matters to you. Clients value knowing that they and the group matter to you. I (ML) attended a group while dealing with a middle ear infection that made it hard for me to hear, which I noted at the start of the session. Nonetheless, we had a productive meeting. Near the end of the session, my ear drum perforated, and liquid began to drain from my ear in obvious fashion. I had not anticipated that this might happen, but group members subsequently referred to the event several times as a reflection of my commitment to the group. It also, not surprisingly, encouraged the group to give me feedback about the importance of my own self-care.
We reinforce members when they testify to the group’s usefulness or comment that they have been thinking about other members during the week. If a member expresses regret that the group will not meet for two weeks over the Christmas holidays, we urge that member to express his or her feelings about their connection to the group. What does it mean to them to cherish the group? To protest its disruption? To have a place in which to describe their concerns openly rather than submerging them? A young man, Marcus, unavoidably missed his last session of a time-limited group treatment but emailed his group leaders with a message that he asked to be shared with the group members. His message had profound impact on the group and group leaders as he articulated his deep appreciation: “The seven months of group therapy has been extraordinary.” He added, “I leave group therapy with my head held up high. I am proud of the person I am and continue to become. I have been humbled to sit, listen and learn from each and every one of you. For this I’m forever indebted to each of you. You have allowed me to mend.” It was a powerful statement of the value of the group.
A well-functioning group continues to work through issues from one meeting to the next: the more continuity between meetings, the better. The therapist does well to encourage continuity. More than anyone else, the therapist is the group historian, connecting events and fitting experiences into the temporal matrix of the group: “That sounds very much like what John was working on two weeks ago,” or, “Ruthellen, I’ve noticed that ever since you and Debbie had that run-in three weeks ago, you have become more depressed and withdrawn. What are your feelings now toward Debbie?”
We rarely start a group meeting by discussing a specific issue other than scheduling and absences, but when we do, it is invariably in the service of providing continuity between meetings. Thus, when it seems appropriate, we might begin a meeting with something like, “The last meeting was very intense! I wonder what types of feelings you took home from the group and what those feelings are now?”
In Chapter 13, we will describe the group summary, a technique that serves to increase the sense of continuity between meetings. For many years, I (IY) wrote a detailed summary of the group meeting each week and mailed it to the members between sessions. The advent of email makes this practice even easier. One of the many important functions of the summary is that it offers the client another weekly contact with the group and increases the likelihood that the themes of a particular meeting will be continued in the following one.
The group increases in importance when members come to recognize it as a rich reservoir of information and support. When members express curiosity about themselves, we, in one way or another, attempt to convey the belief that any information members might desire about themselves is available in the group room, provided they learn how to tap it. Thus, when Ken wonders whether he is too dominant and threatening to others, our reflex is to reply, in effect, “Ken, there are many people who know you very well in this room. Why not ask them?”
Events that strengthen bonds between members enhance the potency of the group. It bodes well when the whole group holds long discussions in the parking lot or goes out for coffee after a meeting, as long as it does not lead to secrets and subgrouping. (Such extragroup contact is not without potential adverse effects, as we shall discuss in detail in Chapter 11.)
Members as Agents of Help
The group functions best if its members appreciate the valuable help they can provide one another. If the group continues to regard the therapist as the sole source of aid, then it is most unlikely that the group will achieve an optimal level of autonomy and self-respect. To reinforce this norm, the therapist may call attention to incidents demonstrating the mutual helpfulness of members. The therapist may also teach members more effective methods of assisting one another. For example, after a client, Reid, has been working with the group on some issue for a long portion of a meeting, the therapist may ask, “Reid, could you think back over the last forty-five minutes? Which comments have been the most helpful to you and which the least?”
Another example: “Brandon, I can see you’ve been wanting to talk about that for a long time in the group and until today you’ve been unable to. Somehow Aliya helped you to open up. What did she do? And what did Ben do today that seemed to close you down rather than open you up?” Behavior undermining the norm of mutual helpfulness should not be permitted to go unnoticed. If one member challenges another concerning his treatment of a third member, stating, for example, “Fred, what right do you have to talk to Antonio about that? You’re a hell of a lot worse off than he is in that regard,” you might intervene by commenting, “Phil, I think you’ve got some negative feelings about Fred today, perhaps coming from somewhere else in your life. Maybe we should get into that. I can’t, however, agree with you when you say that because Fred is similar to Antonio, he can’t be helpful. In fact, here in the group, quite the contrary has often been true.”
Support and Confrontation
As we emphasized in our discussion of cohesiveness, it is essential that the members perceive their therapy group as safe and supportive. Ultimately, in the course of therapy, many uncomfortable issues must be broached and explored. Many clients have problems with rage or are arrogant or condescending or insensitive or just plain cantankerous. The therapy group cannot offer help without such traits emerging during the members’ interactions. In fact, their emergence is to be welcomed as a therapeutic opportunity. Ultimately, conflict must occur in the therapy group, and, as we will discuss in Chapter 11, conflict is essential for the work of therapy. At the same time, however, too much conflict early in the course of a group can cripple its development. Before members feel free enough to express disagreement, they must feel safe enough and must value the group highly enough to be willing to tolerate uncomfortable meetings.
Thus, the therapist must build a group with norms that permit conflict, but only after firm foundations of safety and support have been established. It is often necessary to intervene to prevent the proliferation of too much conflict too early in the group, as the following incident illustrates:
> In a new therapy group, there were two particularly hostile members, and by the third meeting there was a considerable amount of open sniping, sarcasm, and conflict. The fourth meeting was opened by Sofia (one of these two members), who emphasized how unhelpful the group had been to her thus far. Sofia had a way of turning every positive comment made to her into a negative, combative one. She complained, for example, that she could not express herself well, and that there were many things she wanted to say but was so inarticulate she couldn’t get them across. When another member of the group disagreed and stated that she found Sofia to be extremely articulate, Sofia challenged the other member for doubting her judgment about herself. Later in the group, she complimented another member by stating, “Ilene, you’re the only one here who’s ever asked me an intelligent question.” Obviously, Ilene was made quite uncomfortable by this hexed compliment.
At this point I (IY) felt it was imperative to challenge the norms of hostility and criticism that had developed in the group and I intervened forcefully by asking Sofia, “What are your guesses about how your statement to Ilene makes others in the group feel?”
Sofia hemmed and hawed but finally offered that they might possibly feel insulted. I suggested that she check that out with the other members of the group. She did so and learned that her assumption was correct. Not only did every member of the group feel insulted, but Ilene also felt irritated and put off by the statement. I then inquired, “Sofia, it looks as though you’re correct: you did insult the group. Also, it seems that you knew that this was likely to occur. But what’s puzzling is the payoff for you. What do you get out of it?”
Sofia suggested two possibilities. First, she said, “I’d rather be rejected for insulting people than for being nice to them.” That seemed a piece of twisted logic but nonetheless comprehensible. Her second statement was, “At least this way I get to be the center of attention.” “Like now?” I asked. She nodded. “How does it feel right now?” I wondered. Sofia said, “It feels good.” “How about in the rest of your life?” I asked. She responded sadly, “It’s lonely. In fact, this is it. This group—you folks, are the people in my life.” I ventured, “Then this group is a really important place for you?” Sofia nodded. I commented, “Sofia, you’ve always stated that one of the reasons you’re critical of others in the group is that there’s nothing more important than total honesty. If you want to be absolutely honest with us, however, I think you’ve got to tell us also how important we are to you and how much you like being here. That you never do, and I wonder if you can begin to investigate why it is so painful or dangerous for you to show others here how important they are to you.”
By this time Sofia had become much more conciliatory, and I was able to obtain more leverage by enlisting her agreement that her hostility and insults did constitute a problem for her and that it would help her if we called her on it—that is, if we instantaneously labeled any insulting behavior on her part. It is always helpful to obtain this type of contract from a member: consent that in future meetings, the therapist can confront the member about some particular aspect of behavior that the member has asked to be called to his or her attention. Since such clients will then experience themselves as allies in this spotting and confrontative process, they are far less likely to feel defensive about the intervention. << Many of these examples of therapist behavior may seem heavy-handed, or even pontifical. They are not the nonjudgmental, nondirective, mirroring, or clarifying comments we would hope to hear from a therapist at other points in the therapeutic process. It is vital, however, that the therapist attend deliberately to the tasks of group creation and culture building. What happens in the group either builds therapeutic opportunity or hampers it. These tasks underlie and, to a great extent, precede much of the other work of the therapist. It is time now to turn to the third basic task of the therapist: the activation and illumination of the here-and-now. Chapter 6 The Therapist Working in the Here-and-Now A MAJOR DIFFERENCE BETWEEN A PSYCHOTHERAPY GROUP that hopes to effect extensive and enduring behavioral and characterological change and other kinds of groups—twelve-step groups, psychoeducational groups, social skills training groups, and cancer support groups—is that the psychotherapy group strongly emphasizes the importance of the here-and-now experience. Yet all group approaches, including highly structured groups that use the group only as a setting to deliver an intervention, benefit from the group therapist’s capacity to recognize, understand, and utilize the here-and-now. Therapists who are aware of group dynamics and the nuances of the relationships between all the members of the group are more adept at working on the group task even when deeper group and interpersonal exploration or interpretation is not the therapy focus.1 In Chapter 2, we presented some of the theoretical underpinnings of the use of the here-and-now. Now it is time to focus on the clinical application of the here-and-now in group therapy. First, keep in mind this important principle—perhaps the single most important point we make in this entire book: The here-and-now focus, to be effective, consists of two symbiotic tiers, neither of which has full therapeutic power without the other. The first tier is an experiencing one: the members live in the here-and-now, and they develop strong feelings toward the other group members, the therapist, and the group. These here-and-now feelings become the major discourse of the group. The thrust is ahistorical: The immediate events of the meeting take precedence over events both in the current outside life and in the distant past of the members. This focus greatly facilitates the development and emergence of each member’s social microcosm. It facilitates feedback, catharsis, meaningful self-disclosure, and acquisition of socializing techniques. The group becomes more vital, and all of the members (not only the ones directly working in that session) become intensely involved in the meeting. But the here-and-now focus rapidly reaches the limits of its usefulness without the second tier, which is the illumination of process. If the powerful therapeutic factor of interpersonal learning is to be set in motion, the group must recognize, examine, and understand process. It must examine itself; it must study its own transactions; it must transcend pure experience and apply itself to the meaningful integration—the making-sense aspect—of that experience. Thus, the effective use of the here-and-now requires two steps: the group lives in the here-and-now, and it also doubles back on itself and examines the here-and-now behavior that has just occurred. If only the first—the experiencing of the here-and-now—is present, the group experience will still be intense, members will feel deeply involved, emotional expression may be high, and members will finish the group agreeing, “Wow, that was a powerful experience!” Yet it will also prove to be an evanescent experience. Members will have no cognitive framework permitting them to retain the group experience, to generalize from it, to identify and alter their interpersonal behavior, and to transfer their learning from the group to situations beyond the group. This is precisely the error made by many group leaders during the encounter group era. If, on the other hand, only the second part of the here-and-now—the examination of process—is present, then the group loses its liveliness and meaningfulness. It devolves into a sterile intellectual exercise. This is the error made by overly formal, aloof, rigid therapists. Accordingly, the therapist has two discrete functions in the here-and-now: to steer the group into the here-and-now and to facilitate the self-reflective loop (or process commentary). Much of the here-and-now steering function can be shared by the group members, but for reasons we will discuss later, process commentary remains largely the task of the therapist. The majority of group therapists understand that their emphasis must be on the here-and-now. Though it is challenging to maintain that focus, it is an essential component of effective group therapy and correlates with improved clinical outcomes.2 A large survey of seasoned group therapists underscored activation of the here-and-now steering function can be shared by the group members, but for reasons we will discuss later, process commentary remains largely the task of the therapist. The majority of group therapists understand that their emphasis must be on the here-and-now. Though it is challenging to maintain that focus, it is an essential component of effective group therapy and correlates with improved clinical outcomes.2 A large survey of seasoned group therapists underscored activation of the here-and-now as a core skill of the contemporary group therapist.3 A smaller but careful study codified group therapists’ interpretations and found that over 60 percent of interpretations focused on the here-and-now (either behavioral patterns or impact of behavior), while approximately 20 percent focused on historical causes and 20 percent on motivation.4 DEFINITION OF PROCESS The term process, used liberally throughout this text, has a highly specialized meaning in many fields, including law, anatomy, sociology, anthropology, psychoanalysis, and descriptive psychiatry. In interactional psychotherapy, too, process has a specific technical meaning. It refers to the nature of the relationships between interacting individuals—members and therapists.5 Moreover, as we shall see, a full understanding of process must take into account a large number of factors, including the internal psychological worlds of each member, interpersonal interactions, group-as-a-whole forces, the clinical setting of the group, and the larger sociocultural or political environment in which the group is embedded.6 It is useful to contrast process with content. Imagine two individuals in a discussion. The content of that discussion consists of the explicit words spoken, the substantive issues, the arguments advanced. The process is an altogether different matter. When we ask about process, we ask, “What do these explicit words and the style of the participants reveal about the interpersonal relationship of the participants?” Therapists who are process-oriented are concerned not primarily with the verbal content of a client’s statement, but with the “how” and the “why” of that statement, especially insofar as the how and the why illuminate aspects of the client’s interpersonal relationships. Thus, therapists focus on the metacommunicationali aspects of the message and wonder why, from the relationship aspect, an individual makes a statement at a certain time in a certain manner to a certain person. Some of the message is conveyed verbally and directly; some of the message is expressed paraverbally (by nuance, inflection, pitch, and tone); and some of the message is expressed behaviorally, and even somatically, through one’s posture and physical presence.7 Identifying the connection between the intent and the actual impact of the communication is at the heart of the therapy process. Such an exploration illuminates, within the social microcosm of the group, the individual’s interpersonal patterns, beliefs, fears, and wishes. Consider, for example, this transaction: During a lecture, a student raised her hand and asked when the American Psychiatric Association had stopped labeling homosexuality as a mental disorder. The lecturer replied, “1974,” only to have the student inquire, “But wasn’t it earlier, in 1973?” Since the student already knew the answer to her question, her motivation was obviously not a quest for information. (A question ain’t a question if you know the answer.) The process of this transaction? Most likely, the student wished to demonstrate her knowledge, or to humiliate or defeat the lecturer! Frequently, the understanding of process in a group is more complex than in a two-person interaction. We must search for the process not only behind individual statements but behind a sequence of statements made by several group members. The group therapist must endeavor to understand what a particular sequence reveals about the relationship between one client and the other group members, or between clusters or cliques of members, or between the members and the leader, or, finally, between the group as a whole and its primary task. John Schlapobersky, a prominent group analyst, encourages group leaders to reflect regularly on the following as a way to examine group process: Who is speaking? Who is being spoken to? What is being said and what is not being said?8 A clinical vignette may further clarify the concept: > Early in the course of a group therapy meeting, Burt, a tenacious, intense graduate student, exclaimed to the group in general, and to Rose (an unsophisticated mother of four), in particular, “Parenthood is degrading!” This provocative statement elicited considerable response from the group members, all of whom had parents and many of whom were parents. The free-for-all that followed consumed the remainder of the group session. << Burt’s statement can be viewed strictly in terms of content. In fact, this is precisely what occurred in the group; the members engaged Burt in a debate about the virtues versus the dehumanizing aspects of parenthood—a discussion that was affect-laden but impersonal and intellectualized and brought none of the members closer to their goals in therapy. Subsequently, the group felt discouraged about the meeting and angry with themselves and with Burt for having wasted a session. On the other hand, the therapist might have considered the process of Burt’s statement from any one of a number of perspectives: 1. Why did Burt attack Rose? What was the interpersonal process between them? In fact, the two had had a smoldering conflict for many weeks, and in the previous meeting Rose had wondered aloud why, if Burt was so brilliant, he was still, at the age of thirty-two, a student. Burt viewed Rose as an inferior being who functioned primarily as a breast-milk dispensary; once, when she was absent, he referred to her as a brood mare. 2. Why was Burt so judgmental and intolerant of nonintellectuals? Why did he always have to maintain his self-esteem by standing on the carcass of a vanquished or humiliated adversary? 3. Assuming that Burt’s chief intent was to attack Rose, why did he proceed so indirectly? Is this characteristic of Burt’s expression of aggression? Or is it characteristic of Rose that no one dares, for some unclear reason, to attack her directly? 4. Why did Burt, through an obviously provocative and indefensible statement, set himself up for a universal attack by the group? Although the lyrics were different, this was a familiar melody for the group and for Burt, who had on many previous occasions placed himself in a similar position. Why? Was it possible that Burt was most comfortable when relating to others in this fashion? He once stated that he had always loved a fight; indeed, he glowed with anticipation at the appearance of a quarrel in the group. His early family environment was one in which there was a lot of fighting. Was fighting, then, a form (perhaps the only available form) of engagement for Burt? 5. The process may be considered from the even broader perspective of the entire group. Other relevant events in the life of the group must be considered. For the past two months, the session had been dominated by Kate, a deviant, disruptive, and partially deaf member who had, two weeks earlier, dropped out of the group with the face-saving proviso that she would return when she obtained a hearing aid. Was it possible that the group needed a Kate, and that Burt was merely filling the required role of scapegoat and channeling aggression away from other targets—like the therapist? 6. Through its continual climate of conflict, through its willingness to spend an entire session discussing in nonpersonal terms a single theme, was the group avoiding something—possibly an honest discussion of members’ feelings about Kate’s rejection by the group, or their guilt or fear of a similar fate? Or were they perhaps avoiding the anticipated perils of self-disclosure and intimacy? 7. Was the group saying something to the therapists through Burt (and through Kate)? For example, Burt may have been bearing the brunt of an attack really aimed at the co-therapists but displaced from them. The therapists—aloof figures with a proclivity for rabbinical pronouncements—had never been attacked or confronted by the group. Their co-therapy relationship had also escaped any comment to date. Surely there were strong unspoken feelings toward the therapists, which may have been fanned by their failure to support Kate and by their complicity through inactivity in her departure from the group. Which one of these many process observations is correct? Which one could the therapists have employed as an effective intervention? The answer is, of course, that any and all may be correct. They are not mutually exclusive; each views the transaction from a slightly different vantage point. What is critical, however, is that the focus on process begins with the therapist’s reflection on the host of factors that may underlie an interaction. By clarifying each of these in turn, the therapist could have focused the group on many different aspects of its life. Which one, then, should the therapist have chosen? It is a daunting question with multiple choice points to pursue, particularly for neophyte group leaders who may respond reactively to one potential dynamic without recognition of the larger patterns or group processes.9 The therapist’s choice should be based on one primary consideration: the immediate needs of the group. What will draw the group’s focus back to those needs? The therapists had many options. If they felt there had been too much focus on Burt of late, leaving the other members feeling bored and excluded, then they might have wondered aloud what the group was avoiding. The therapists might have next reminded the group of previous sessions spent in similar discussions that left them dissatisfied. Or they might have helped one of the members verbalize this point by inquiring about that member’s inactivity or apparent uninvolvement in the discussion. If they felt that the indirectness of the group communication was a major issue, they might have commented on the indirectness of Burt’s attacks, or asked the group to help clarify, via feedback, what was happening between Burt and Rose. If they felt that an exceptionally important group event (Kate’s departure) was being strongly avoided, then they might have focused on that event and the conspiracy of silence around it. > In another group, a member, Saul, sought therapy because of his deep sense of isolation. He was particularly interested in a group therapeutic experience because he had never before been a part of a primary group. Even in his primary family, he had felt himself an outsider. He had been a spectator all his life, pressing his nose against cold windowpanes, gazing longingly at warm, convivial groups within.
At Saul’s fourth therapy meeting, another member, Barbara, began the meeting by announcing that she had just broken up with a man who had been very important to her. Barbara’s major reason for being in therapy had been her inability to sustain a relationship with a man, and she was now profoundly distressed. Barbara had an extremely poignant way of describing her pain, and the group was swept along with her feelings. Everyone in the group was very moved; I (IY) noted silently that Saul, too, had tears in his eyes.
The group members (with the exception of Saul) did everything in their power to offer Barbara support. They passed Kleenex; they reminded her of all her good qualities and assets; they reassured her that she had made the right choice, that the man was not good enough for her, that she was “lucky to be rid of that jerk.”
Suddenly, Saul interjected: “I don’t like what’s going on here in the group today, and I don’t like the way it’s being led” (an obvious allusion to me). He went on to explain that the group members had no justification for their criticism of Barbara’s ex-boyfriend. They didn’t really know what he was like. They could see him only through Barbara’s eyes, and probably she was presenting him in a distorted way. (Saul had a personal ax to grind on this matter, having gone through a divorce a couple of years earlier. His wife had attended a women’s support group, and he imagined he had been the “jerk” of that group.)
Saul’s comments, of course, changed the entire tone of the meeting. The softness and support disappeared. The room felt cold; the warm bond among the members was broken. Everyone was on edge. I felt justifiably reprimanded. Saul’s position was technically correct: the group was wrong to condemn Barbara’s ex-boyfriend in such a sweeping and uncritical manner.
So much for the content. Now let’s examine the process of this interaction. First, note that Saul’s comment had the effect of putting him outside the group. The rest of the group was caught up in a warm, supportive atmosphere from which he excluded himself. Recall his chief complaint that he was never a member of a group, but always the outsider. The meeting provided an in vivo demonstration of how that came to pass. In his fourth group meeting, Saul had, kamikaze-style, attacked and voluntarily ejected himself from a group he wished to join.
A second issue had to do not with what Saul said but what he did not say. In the early part of the meeting, everyone except Saul had made warm, supportive statements to Barbara. I had no doubt that Saul felt supportive of her; the tears in his eyes indicated that. But why had he chosen to be silent? Why did he always choose to respond from his critical self and not from his warmer, more supportive self?
The examination of this aspect of the process led to some very important issues for Saul. Obviously, it was difficult for him to express the softer, affectionate part of himself. He feared being vulnerable and exposing his dependent cravings. He feared losing himself and his own uniqueness by getting too close to another or becoming a member of a group. Behind the aggressive, ever-vigilant, hard-nosed defender of honesty (but a selective honesty: honesty of expression of negative but not positive sentiments), there is often the softer, submissive child thirsting for acceptance and love. << > In a T-group (an experiential training group) of clinical psychology interns, one of the members, Robert, commented that he genuinely missed the contributions of some of the members who had been generally very silent. He turned to two of these members and asked if there was anything he or others could do that would help them participate more. The two members and the rest of the group responded by launching a withering attack on Robert. He was reminded that his own contributions had not been substantial, that he was often silent for entire meetings himself, that he had never really expressed his emotions in the group, and so forth.
Viewed at the content level, this transaction is bewildering. Robert expressed genuine concern for the silent members, and for his solicitude he was soundly buffeted. Viewed at the process—that is, relationship—level, however, it makes perfectly good sense: the group members were involved in a struggle for dominance, and their inner response to Robert’s statement was, “Who are you to issue an invitation to speak? Are you the host or leader here? If we allow you to comment on our silence and suggest solutions, then we acknowledge your dominion over us.” << > In another group, Kevin, an overbearing business executive, opened the meeting by asking the other members—housewives, teachers, clerical workers, freelance software developers, and store owners—for help with a problem: he had received “downsizing” orders. He had to cut his staff immediately by 50 percent—to fire twenty of his staff of forty.
The content of the problem was intriguing but impersonal. The group spent forty-five minutes discussing such aspects as justice versus mercy: that is, whether one retains the most competent workers or workers with the largest families or those who would have the greatest difficulty in finding other jobs. Despite the fact that most of the members engaged animatedly in the discussion, which involved important problems in human relations, the co-therapists regarded the session as unproductive: the discussion could have appropriately occurred at a dinner party or any other social gathering. Furthermore, as time passed, it became abundantly clear that Kevin had already spent considerable time thinking through every aspect of the problem, and no one was able to provide him with novel approaches or suggestions. The session was not truly a work session: instead it was a flight-from-work session.
Such a dedicated focus on content is inevitably frustrating for the group, and the therapists began to wonder about process—that is, what this content revealed about the nature of Kevin’s relationship to the other members. As the meeting progressed, Kevin, on two occasions, let slip the amount of his salary (which was more than double that of any other member). In fact, the overall interpersonal effect of Kevin’s presentation was to make others aware of his affluence and power.
The process became even more clear when the therapists recalled previous meetings in which Kevin had been soundly attacked by the group for his evangelical religious convictions, which he used to criticize others’ behavior but never his own—which included extramarital affairs and compulsive lying. At a recent meeting, he had been termed “thick-skinned” because of his apparent insensitivity to others. However, despite the criticism he had received, Kevin was a dominant member: he was the most active and central figure in almost every meeting.
With this information about process, let’s examine the alternatives available to consider. The therapists might have focused on Kevin’s bid for prestige, especially after the attack on him and his loss of face in the previous meeting. Phrased in a nonaccusatory manner, a clarification of this sequence might have helped Kevin become aware of his desperate need for the group members to respect and admire him. At the same time, the self-defeating aspects of his behavior could have been pointed out. Despite his yearning for respect, the group had come to resent and at times even to scorn him. Perhaps, too, Kevin was attempting to repudiate the charge of being thick-skinned by sharing his personal agony over the staffing issue in such a melodramatic fashion.
There are many therapist options. The style of the therapists’ intervention would depend on Kevin’s degree of defensiveness: if he had seemed particularly brittle or prickly, then the therapists might have underscored how hurt he must have been at the previous meeting. If he had been more open, they might have asked him directly what type of response he would have liked from the others.
Other therapists might have preferred to interrupt the content discussion and simply ask the group members what Kevin’s question had to do with last week’s session. Still another alternative would be to call attention to an entirely different type of process by reflecting on the group’s apparent willingness to permit Kevin to occupy center stage in the group week after week. By encouraging the members to discuss their response to his monopolization, the therapist could have helped the group initiate an exploration of their relationship with Kevin. <<
Keep in mind that therapists need not wait until they have all the answers before asking a process question. In fact, the initial process inquiry may be essential in understanding the process, and rather than waiting for greater certainty, therapists may begin the process inquiry by simply asking the members a question at a very low level of inference: “How are each of you experiencing the meeting so far?” Or they may use slightly more inference: “You look like you are having some reaction to this.” At other times, the therapist’s level of inference may be raised and interventions may be more precise and ultimately interpretive: “Kevin, I have a sense that you yearn for respect here in the group, and I wonder if the comment last week about you being ‘thick-skinned’ wasn’t hurtful to you and is related to your bringing in this work dilemma.”
Although our focus is on group therapy applications, the skills of process recognition and metacommunication makes group therapy training indispensable to mental health professionals across all forms of practice. It is a form of X-ray vision that helps us see what team or organizational dynamics may lie beneath the more manifest communication, as the following example illustrates:
> As chief of psychiatry in a university teaching hospital, I (ML) was involved in planning meetings regarding the impending COVID-19 pandemic. Several years previously, our hospital and surrounding community had been severely impacted by the severe acute respiratory syndrome pandemic (SARS).10 Many of our staff members had been quarantined; some became gravely ill and required ICU care; and a number of nurses and doctors in our surrounding community had succumbed to SARS.
In this planning meeting involving all of the hospital’s department chiefs and our senior administrative leadership, the discussion became progressively more polarized and more heated. One senior member felt that we were heading for a catastrophe of epic proportion. Another senior member responded that that was a grossly exaggerated and dramatic response and that we would weather it without much impact. Emotional tensions grew, the polarization deepened, and we were approaching an impasse.
At that point I commented that it would be helpful to look at this discussion from a psychological perspective. “It is human nature, after our SARS trauma, that our reactions in the face of a potential new threat range from feelings of powerful reexperiencing and deep dread, on the one hand, and avoidance, minimization, or denial, on the other hand. Both polarized reactions carry some elements of truth; both need to be integrated into meaningful planning for the hospital, our patients and staff.”
That process intervention identified and defused our mounting tensions and we were able to resume our task and planning process with greater mutual understanding. << PROCESS FOCUS: THE POWER SOURCE OF THE GROUP The focus on process—that is, on the here-and-now—is not just one of many possible procedural orientations; on the contrary, it is indispensable and a common denominator of all effective interactional groups. One so often hears words to this effect: “No matter what else may be said about experiential groups (therapy groups, T-groups, group therapy conference institute groups, and so on), one cannot deny that they are potent—that they offer a compelling experience for participants.” Why are these groups potent? Precisely because they encourage process exploration. The process focus is the power cell of the group. A process focus is the one truly unique feature of the experiential group; after all, there are many socially sanctioned activities in which one can express emotions, help others, give and receive advice, confess secrets, and discover similarities between oneself and others. But where else is it permissible, in fact encouraged, to comment, in depth, on here-and-now behavior—on the nature of the immediately current relationship between people? Consider the cocktail party. Imagine confronting a narcissistic, self-absorbed individual who looks through or over you while talking to you, searching for someone more attractive or appealing. In place of an authentic encounter, we are most likely to comment, “Good talking with you…” or, “I need to refill my drink…”—rather than, “Are you aware that you are talking to me while scanning the room for more attractive people? Do you know how that makes me feel?” The cocktail party is not the place for authentic process examination: most likely it would result in a dramatic decrease of one’s party invitations. Process commentary among adults is generally taboo social behavior; it is considered rude, intrusive, or impertinent. Positive comments about another’s immediate behavior often denote a seductive or flirtatious relationship. Negative comments about another’s manners, gestures, speech, or physical appearance foreshadow a bitter battle looming ahead. Why should this be so? What are the sources of this taboo? One researcher suggested that process commentary is eschewed in social interaction because of socialization anxiety, social norms, fear of retaliation, and power maintenance.11 Socialization Anxiety Process commentary evokes early memories and anxieties associated with parental criticism of the child’s behavior. Parents comment on the behavior of children. Although some of this process focus is positive, much more is critical and serves to control and alter the child’s behavior. Adult process commentary often awakens old socialization-based anxiety and is experienced as judging, critical, and controlling. Social Norms If individuals felt free to comment at all times on the behavior of others, social life would become intolerably self-conscious, complex, and conflicted. Underlying adult interaction is an implicit contract that a great deal of immediate behavior will be invisible to the parties involved. This provides an autonomy and a freedom that would be impossible if we all knew that others were continually observing our behavior and were free to comment on it. This is a lesson often taught to many young therapists by their partners: “Don’t try that stuff with me at home…” Fear of Retaliation We cannot monitor or stare at another person too closely, because (unless the relationship is exceedingly intimate) such intrusiveness is almost always dangerous and anxiety-provoking and evokes retribution. There exist no forums, aside from such intentional systems as therapy groups, for interacting individuals to test and to correct their observations of one another. Power Maintenance Process commentary undermines arbitrary authority structure. Organizational consultants have long known that an organization’s open investigation of its own structure and process leads to power equalization—that is, a flattening of the hierarchical pyramid. The more rigid the authority structure of an organization, the more stringent the precautions against open commentary about process (as in, for example, the military or the church). The individual who wishes to maintain a position of arbitrary authority is wise to inhibit the development of any rules permitting reciprocal process observation and commentary. In psychotherapy, process commentary involves a great degree of therapist transparency, exposure, and even intimacy: many therapists resist this approach because of their own uneasiness about the hierarchical flattening that ensues.12 THE THERAPIST’S TASKS IN THE HERE-AND-NOW In the first stage of the here-and-now focus—the activating phase—the therapist’s task is to move the group into the here-and-now. By a variety of techniques, which we will discuss shortly, group leaders steer the group members away from outside material and focus instead on their relationship with one another. Group therapists expend more time and effort on this task early than late in the course of the group, because as the group matures, the members begin to share much of this task, and the here-and-now focus often becomes a natural part of the group flow. In fact, many of the norms described in the previous chapter, which the therapist must establish in the group, foster a here-and-now focus. For example, the leader who sets norms of interpersonal feedback, of emotional expression, of self-monitoring, of valuing the group as an important source of information, is, in effect, reinforcing the importance of the here-and-now. Gradually, members, too, come to value the here-and-now and will themselves focus on it; by a variety of means, they will also encourage their fellow members to do likewise. It is altogether another matter with the second phase of the here-and-now orientation, process illumination. Forces prevent members from fully sharing that task with the therapist. Recall the earlier T-group vignette, when a group member made observations about what was happening in the group, and the others responded resentfully about his presumptuousness in seeking to elevate his status above the others. Similar instances abound. If a member comments, for example, that “nothing is happening today,” or that “the group is stuck,” or that “no one is self-revealing,” or that “there seem to be strong feelings toward the therapist,” then that member is courting danger. The response of the other members is predictable. They will challenge the challenging member: “You make something happen today,” or “You reveal yourself,” or “You talk about your feelings toward the therapist.” Only the therapist is relatively exempt from that charge. Only the therapist has the right to suggest that others work or that others reveal themselves without having to engage personally in the act he or she suggests. Throughout the life of the group, the members are involved in a struggle for position on the hierarchy of dominance. At times, the conflict around control and dominance is flagrant; at other times, quiescent. But it never vanishes and should be explored in therapy, both because it is a rich source of material and to prevent it from hardening into a source of continuing, fractious conflict. Some members strive nakedly for power; others strive subtly; still others desire it but are fearful of assertion, or always assume an obsequious, submissive posture. Statements by members that suggest that they place themselves above or outside the group generally evoke responses that emerge from the dominance struggle rather than from consideration of the content of the statement. Even therapists are not entirely immune from evoking this response; some clients are inordinately sensitive to being controlled by the therapist. They find themselves in the paradoxical position of applying to the therapist for help and yet being unable to accept help, because all statements by the therapist are viewed through spectacles of distrust. This is a function of the specific pathology of some clients (and it is, of course, good grist for the therapeutic mill). The therapist is an observer-participant in the group. The observer status affords the objectivity necessary to store information, to make observations about sequences or cyclical patterns of behavior, and to connect events that have occurred over long periods of time. Therapists act as group historians. Only they are permitted to maintain a temporal perspective; only they remain immune from the charge of not being one of the group, of elevating themselves above the others. It is also chiefly the therapists who keep in mind the original goals of the group members and the relationship between these goals and the events that gradually unfold in the group.13 > Two group members, Tim and Marjorie, had a sexual affair that eventually came to light in the group. The other members reacted in various ways, but none so condemnatory or so vehemently as Diana, a harsh forty-five-year-old moralist who criticized them for breaking group rules: Tim, for “being too intelligent to act like such a fool,” Marjorie for her “irresponsible disregard for her husband and child,” and the libertine therapist (IY) who “just sat there and let it happen.” I eventually pointed out that, in her formidable moralistic broadside, some individuals had been obliterated, that the Marjorie and Tim whom Diana had known for so long, with all their struggles and doubts and fears, had suddenly been replaced by faceless one-dimensional stereotypes. Furthermore, I was the only one to recall, and to remind the group of, the reasons (expressed at the first group meeting) why Diana had sought therapy: namely, that she needed help in dealing with her rage toward a rebellious nineteen-year-old daughter who was in the midst of a sexual awakening and searching for her identity and autonomy! From there it was but a short step for the group, and then for Diana herself, to understand that her conflict with her daughter was being played out in the here-and-now of the group. << There are many occasions when the process is obvious to all the members in the group but cannot be commented upon simply because the situation is too hot: the members are too much a part of the interaction to separate themselves from it. In fact, often, even at a distance, the therapist, too, feels the heat and is wary about naming the beast. Sometimes an inexperienced therapist may naively determine it best that some group member speak to an issue in the group that the leader himself feels too anxious to address. That is usually an anxiety-driven error: the therapist has developed, we hope, a greater ability to speak the unspeakable and to find palatable ways to say unpalatable things than the client. Language is to the therapist what the scalpel is to the surgeon. > One neophyte leader facilitating an experiential group of pediatric oncology nurses (a support group intended to help members decrease the stress experienced in their work) inferred through the collusive glances between members in the first meeting that there was considerable unspoken tension between the young, progressive nurses and the older, conservative charge nurses in the group. The leader felt that the issue, reaching deep into taboo regions of authority and tradition, was too sensitive and potentially explosive to touch. Her supervisor assured her that it was too important an issue to leave unexplored and that she should broach it, since it was highly unlikely that anyone else in the group could do what she dared not.
In the next meeting, she raised the issue in a manner that is almost invariably effective in minimizing defensiveness: she described her own dilemma about the issue. She told the group that she sensed a hierarchical struggle between the junior nurses and the powerful senior nurses, but that she was hesitant to bring it up lest the younger nurses either deny it or attack their supervisors, who might be so wounded that they would decide to scuttle the group. Her comment was enormously helpful and plunged the group into an open and constructive exploration of a vital issue. << Articulating the dilemma in a balanced, nonblaming, self-revealing fashion is often the most effective way to reduce the tension that obstructs the group’s work. Group leaders need not have a complete answer to the dilemma—but they do need to be able to identify and speak to it. By no means do we suggest that only the leader should make process comments. As we shall discuss later, other members are entirely capable of performing this function; in fact, there are times when their process observations will be more readily accepted by group members than those of the therapists. Cultivating an ability to recognize process in interactions—a form of emotional intelligence, perhaps—is an important outcome of group therapy that will serve members well in life. (Often, students observing a mature group at work are amazed by group members’ high level of psychological-mindedness.) It is a good thing for members to learn to identify and comment on process. But it is important that they not assume this function for defensive reasons—for example, to avoid the client role or in any other way to remove themselves from the group work. Thus far in this discussion we have, for pedagogical reasons, overstated two fundamental points that we must now qualify. Those points are: (1) the here-and-now approach is an ahistorical one, and (2) there is a sharp distinction between here-and-now experience and here-and-now process illumination. Strictly speaking, an ahistorical approach is an impossibility: every process comment refers to an act that already belongs to the past. Not only does process commentary involve behavior that has just transpired, but it frequently refers to cycles of behavior or repetitive acts that have occurred in the group over weeks or months. Thus, the past events of the therapy group are a part of the here-and-now and an integral part of the data on which process commentary is based. Often it is helpful to ask clients to review their past experiences in the group. If a member feels that she is exploited every time she trusts someone or reveals herself, it is good to inquire about her history of experiencing that feeling in the group. Other clients, depending upon the relevant issues, may be encouraged to discuss such experiences as the times they have felt the closest to others, the angriest, the most accepted, or the most ignored. It is wise to search for analogues in the room of relationships and situations in the outside world. Our qualification of the ahistorical approach goes even further. As we will discuss later in a separate section in this chapter, no group can maintain a total here-and-now approach. There will be frequent excursions into the “then-and-there”—that is, into personal history and into current life situations. In fact, such excursions are so inevitable that one becomes curious when they do not occur. It is not that the group doesn’t deal with the past; it is what is done with the past. The crucial task is not to uncover, to piece together, to fully understand the past, but to use the past for the help it offers in understanding (and changing) the individual’s mode of relating in the present. It is a matter of relative emphasis—a form of figure-ground phenomena. Keep in mind that this does not usually make intuitive sense to our clients, who anticipate that therapy will be a deep dive into their past. (More about that when we address pregroup preparation.) The distinction between here-and-now experience and here-and-now process commentary is not sharp; there is much overlap. For example, low-inference commentary (feedback) is both experience and commentary. When one member remarks that another refuses to look at her, or that she is furious at another for continually deprecating her, she is at the same time commenting on process and involving herself in the affective here-and-now experience of the group. Process commentary exists for only a short time; it rapidly becomes incorporated into the experiential flow of the group and forms part of the data from which future process comments will flow. For example, in an experiential group of mental health trainees (a group experience that was part of their group therapy training curriculum), one member, Paulo, began the session by describing his extreme feelings of depression and depersonalization. Instead of exploring the member’s dysphoria, the group immediately began offering him practical advice about his life situation. The leader commented on the process—on the fact that the group veered away from inquiring more about Paulo’s experience. The leader’s intervention seemed useful: the group members became more emotionally engaged, and several discussed their admiration of Paulo’s risk-taking and their own fear of self-revelation. Soon afterward, however, a couple of members who predictably challenged the leader’s influence stated their objections to this intervention. They felt that the leader was dissatisfied with their performance in the group, that he was criticizing them, and, in his usual subtle manner, was manipulating the group to fit in with his preconceived notions of the proper conduct of a meeting. Other members took issue with the tendency of some members to challenge every move of the therapist. Thus, the leader’s process comments became part of the experiential ebb and flow of the group. Even the members’ criticism of the leader (which was at first process commentary) soon also became part of the group experience, and itself subject to process commentary. The processing of the group experience can go deeper and deeper if we are willing to take it there and not leave important material unexamined. Summary The effective use of the here-and-now focus requires two steps: experience in here-and-now and process illumination. The combination of these two steps imbues an experiential group with compelling potency. The therapist has different tasks in each step. First, the group must be plunged into the here-and-now interactional experience; second, it must be helped to understand the process of the here-and-now experience—that is, what the interaction conveys about the nature of the members’ relationships with one another. The first step, here-and-now activation, becomes part of the group norm structure; eventually the group members will assist the therapist in this task. The second step, process illumination, is more difficult. There are powerful injunctions against process commentary in everyday social interaction that the therapist must overcome. The task of process commentary, to a large extent (but not exclusively), remains the responsibility of the therapist and consists, as we will discuss shortly, of a wide and complex range of behavior—from labeling single behavioral acts, to juxtaposing several acts, to combining acts over time into a pattern of behavior, to pointing out the undesirable consequences of a client’s behavioral patterns, to identifying here-and-now behaviors that are analogues to the member’s behavior in the world at large, to more complex inferential explanations or interpretations about the meaning and motivation of such behavior. TECHNIQUES OF HERE-AND-NOW ACTIVATION In this section we wish to describe (but not prescribe) some techniques for establishing a here-and-now orientation in group therapy. Each therapist must develop techniques consonant with his or her personal style. Indeed, therapists have a more important task than mastering a technique: they must fully comprehend the strategy and theoretical foundations upon which all effective technique must rest.14 Trainees often are very interested in the specific language their supervisors or experts employ with their interventions. More important than copying the language, however, is gaining clarity about the principles guiding the selection of these techniques. First step: We suggest that you think here-and-now. When you grow accustomed to thinking of the here-and-now, you automatically steer the group into the here-and-now. Sometimes we feel like shepherds herding a flock into an ever-tightening circle. We head off errant strays—forays into personal historical material, discussions of current life situations, politics, the economy—and guide them back into the circle. Whenever an issue is raised in the group, we think, “How can we relate this to the group’s primary task? How can we make it come to life in the here-and-now?” We are relentless in this effort, and begin it in the very first meeting of the group. Consider a typical first meeting of a group. After a short, awkward pause, the members generally introduce themselves and proceed, often with help from the therapist, to tell something about their life problems, why they have sought therapy, and perhaps the type of distress they suffer. We generally intervene at some convenient point well into the meeting and make a remark such as, “We’ve done a great deal here today so far. Each of you has shared a great deal about yourself, your pain, your reasons for seeking help. But we have a hunch that something else is also going on, and that is that you’re sizing one another up, each arriving at some impressions of the others, each wondering how you’ll fit in with the others. Could we spend some time discussing what each of us has come up with thus far?” Now this is no subtle, artful statement: it is heavy-handed, explicit, and directive. Yet most groups respond favorably to such clear guidelines and readily appreciate the therapeutic facilitation. Group members will not go there without that encouragement. Articulating the purpose and methodology of your interventions will demystify the group and foster better alignment around goals, tasks, and relationships. It also sets the stage for creating the social microcosm necessary for potential corrective emotional experiences to emerge.15 The therapist is on a perpetual mission, moving the focus from outside the group to inside the group, from the abstract to the specific, from the generic to the personal, from the personal into the interpersonal. If a member describes a hostile confrontation with a spouse or roommate, the therapist may, at some point, inquire, “If you were to be angry like that with anyone in the group, with whom would it be?” or, “With whom in the group can you foresee getting into the same type of struggle?” If a member comments that one of his problems is that he lies, or that he stereotypes people, or that he manipulates groups, the therapist may inquire, “What is the main lie you’ve told in the group thus far?” or, “Can you describe the way you’ve stereotyped some of us?” or, “To what extent have you manipulated the group thus far?” If a client complains of mysterious flashes of anger or suicidal compulsions, the therapist may urge the client to signal to the group the very moment such feelings occur during the session, so that the group can track down and relate these experiences to events in the session. If a member describes her problem as being too passive, too easily influenced by others, the therapist may move her directly into the issue by asking, “Who in the group could influence you the most? The least?” These interventions are useful even in very brief groups, such as on inpatient units, with the proviso that the more positive and supportive aspects of the here-and-now engagement be emphasized. It is a misconception, perhaps stemming from more confrontational group models, that working in the here-and-now is divisive and inflammatory. On the contrary, it can be powerfully supportive and emotionally intimate. The therapist must be alert to the risks of shaming or devaluing group members through feedback. The tone the leader sets and models is part of the norm-setting responsibilities we described in the preceding chapter. If a member comments that the group is too polite and too tactful, the therapist may ask, “Who do you think are the leaders of the peace-and-tact movement in the group?” If a member is terrified of revealing himself and fears humiliation, the therapist may bring it into the here-and-now by asking him to identify those in the group he imagines might be most likely to ridicule him. Don’t be satisfied by answers of “the whole group.” Press the member further. Often it helps to rephrase the question in a gentler manner—for example, “Who in the group is least likely to ridicule you?” In each of these instances, the therapist can deepen interaction by encouraging further responses from the others. For example, “How do you feel about his fear or prediction that you would ridicule him? Can you imagine doing that? Do you, at times, feel judgmental in the group?” Even simple techniques of asking group members to speak directly to one another, to use second person (“you”) rather than third-person pronouns, and to look at one another are very useful. It may, at first, feel a bit heavy-handed and far removed from the traditional view of the therapist as neutral, detached, and silent. Keep in mind that group therapists use the here-and-now to activate therapy and promote therapeutic interaction, not because we wish to exercise power or dominion over others. And if the therapist worries that his or her interventions may feel too controlling of others, that, too, can be processed productively, by asking for the group’s feedback about how they are experiencing the group leader(s). Easier said than done! Such group therapist inquiries are not always heeded. To some group members, these suggestions are threatening indeed, and the therapist must here, as always, employ good timing and attempt to experience what the client is experiencing. Search for methods that lessen the threat. For example, begin by focusing on positive interaction: “Toward whom in the group do you feel most warm?” “Who in the group is most like you?” or, “Obviously, there are some strong vibes, both positive and negative, going on between you and John. I wonder what you most envy or admire about him? And what parts of him do you find most difficult to accept?” > Members of a group of elderly clients attending a psychiatric day hospital for treatment of depression groaned with feelings of disconnection and despair. The initial focus of the meeting was Sara—an eighty-seven-year-old Holocaust survivor. Sara lamented the persistent prejudice, hatred, and racism so prominent in the news headlines. Feeling scared and helpless, she discussed her wartime memories of being dehumanized by those who hated her without knowing anything about her as a real person. Group members, including other Holocaust survivors, also shared their tortured memories.
I (ML) attempted to break into the group’s
intense preoccupation with the painful past by shifting into the here-and-now. What did Sara experience in sharing these memories with the group today? Did she feel that the group members were engaging her as a real person? Why had she chosen to be different today—to speak out rather than silence herself as she has done so often before? Could she take credit for that? How did others feel about Sara speaking out in this meeting?
Gradually the meeting’s focus shifted from the recounting of despairing memories to lively interaction, support for Sara, and strong feelings of member connection. << Sometimes, it is easier for group members to work in tandem or in small functional subgroups than to work with the whole group, because it feels less isolating and safer. For example, if clients learn that there is another member (or more) with fears or concerns similar to theirs, then these members can more readily discuss their here-and-now concerns as a less threatened subgroup.16 This may occur spontaneously or by the therapist directly bridging between specific members—for example, by pointing out that the concerns just disclosed by one member have also been expressed by another. Or the therapist can invite a group member who has worked on this particular issue in earlier sessions to comment on what it might be like at this moment for their co-member.17 We seek to capitalize on both the lived experience of our group members and their personal expertise as we bring them into closer contact with one another. Using the conditional verb form provides safety and distance and often is miraculously facilitative. We use it frequently when we encounter initial resistance. If, for example, a client says, “I don’t have any response or feelings at all about Mary today. I’m just feeling too numb and withdrawn,” we often say something like, “If you were not numb or withdrawn today, what might you feel about Mary?” The client generally answers readily; the once-removed position affords a refuge and encourages the client to answer honestly and directly. Similarly, the therapist might inquire, “If you were to be angry at someone in the group, whom would it be?” or, “If you were to go on a date with Albert (another group member), what kind of experience might it be?” The therapist must teach members the art of requesting and offering feedback by explicit instruction, by modeling, or by reinforcing effective feedback.18 One important principle to teach clients is the avoidance of global questions and observations. Specificity and an interpersonal focus help, as does taking a risk in both the giving and receiving of feedback. Questions such as “Am I boring?” or “Do you like me?” are not usually productive. A client learns a great deal more by asking, “What do I do that causes you to tune out?” or, “What parts of me or aspects of my behavior do you like least and most?” In the same vein, feedback such as “You’re okay” or “You’re a nice guy” is far less useful than “I feel closer to you when you’re willing to be honest with your feelings, like in last week’s meeting, when you said you were attracted to Mary but feared she would scorn you. I feel most distant from you when you’re impersonal and start analyzing the meaning of every word said to you, like you did early in the meeting today.” At times, it is not the blandness of feedback that is problematic—it is its sheer hostility. Perhaps the worst and most damaging example of feedback I (ML) have encountered was a member’s explosive burst after weeks of silent, suppressed anger and frustration that had resisted all therapeutic interventions. Sue, a woman with a history of trauma, turned to a very difficult, controlling, and devaluing narcissistic man in the group and yelled, “Keith, you are subhuman and a waste of oxygen.” Keith turned to me and asked, “How am I supposed to work with that?” Sue’s feedback was so humiliating and wholly rejecting that he was left no path for learning or remediation. Feedback has to contain a path to working in the here-and-now, such as, “Keith, you control and squash this group by the way you criticize us all and monopolize the sessions, leaving no time for anyone else. I am so frustrated and angry because of your disregard for everyone here. Do you want to push us all out of here? How will that help you work on being less isolated and lonely—isn’t that what you told us your goals were?” Resistance occurs in many forms. But generally, it serves the purpose of regulating the client’s pace of recognizing and expressing emotional truth.19 Often it appears in the cunning guise of total equality. Clients, especially in early meetings, often respond to the therapist’s here-and-now urgings by claiming that they feel exactly the same toward all the group members: that is, they say that they feel equally warm toward all the members, or no anger toward any, or equally influenced or threatened by all. Do not be misled. Such claims are never true. Guided by your sense of timing and empathy, push the inquiry further and help members differentiate one another. Eventually they will disclose that they do have slight differences of feeling toward some of the members. These slight differences are important and are often the vestibule to full interactional participation. We explore the slight differences (no one ever said they had to be enormous); sometimes we suggest that the client hold up a magnifying glass to these differences and describe what he or she then sees and feels. Often resistance is deeply ingrained, and the client is heavily invested in maintaining a position that is known and familiar even though it is undermining or personally destructive. Resistance is not usually conscious obstinacy but more often stems from sources outside of awareness. Sometimes the here-and-now task is so unfamiliar and uncomfortable to the client that it is not unlike learning a new language, or it generates an intense sense of vulnerability and fear of retaliation. The client must apply maximal concentration in order not to slip back into habitual modes of relating. Considerable therapist ingenuity is often required to focus the group on the here-and-now, as the following illustration demonstrates: > Claudia resisted participation on a here-and-now level for many sessions. Typically, she brought to the group some pressing current life problem, often one of such crisis proportions that the group members felt trapped. First, they felt compelled to deal immediately with the precise problem Claudia presented; second, they had to tread cautiously, because she explicitly informed them that she needed all her resources to cope with the crisis and could not afford to be shaken up by interpersonal confrontation. “Don’t push me right now,” she might say. “I’m just barely hanging on.” Efforts to alter this pattern were unsuccessful, and the group members felt discouraged in dealing with Claudia. They cringed when she brought problems into the meeting.
One day she opened the group with a typical gambit. After weeks of searching she had obtained a new job, but she was convinced that she was going to fail and be dismissed. The group dutifully but warily investigated the situation. The investigation met with many of the familiar, treacherous obstacles that generally block the path of work on outside problems. There seemed to be no objective evidence that Claudia was failing at work. She seemed, if anything, to be trying too hard, working eighty hours a week. The evidence, Claudia insisted, simply could not be appreciated by anyone not there at work with her: the glances of her supervisor, the subtle innuendos, the air of dissatisfaction toward her, the general ambiance in the office, the failure to live up to her (self-imposed and unrealistic) sales goals. It was difficult to evaluate what she was saying because she was a highly unreliable observer. She typically downgraded herself and minimized her accomplishments.
I (IY) moved the entire transaction into the here-and-now by asking a question. “Claudia, it’s hard for us to determine whether you are, in fact, failing at your job. But let me ask you another question: What grade do you think you deserve for your work in the group, and what do each of the others get?”
Claudia, not unexpectedly, awarded herself a “D–” and staked her claim for at least eight more years in the group. She awarded all the other members substantially higher grades. I replied by awarding Claudia a “B” for her work in the group and then went on to point out the reasons: her commitment to the group, perfect attendance, willingness to help others, great efforts to work despite anxiety and often disabling depression.
Claudia laughed it off, trying to brush off this exchange as a gag or a therapeutic ploy, but I insisted that I was entirely serious. Claudia then insisted that I was wrong and pointed out her many failings in the group (one of which was the avoidance of the here-and-now). However, Claudia’s disagreement with me created dissonance for her, since it was incompatible with her long-held, frequently voiced, total total confidence in me. (Claudia had often invalidated the feedback of other members in the group by claiming that she trusted no one’s judgment except mine.) << The intervention was enormously useful. It transferred the process of Claudia’s evaluation of herself from a secret chamber lined with the distorting mirrors of her self-perception to the open, vital arena of the group. No longer was it necessary for the members to accept Claudia’s perception of her boss’s glares and subtle innuendoes. The boss (the therapist) was there in the group. The whole transaction was visible to the group. Finding the here-and-now experiential analogue of the untrustworthy “then-and-there” reported difficulties unlocked the therapeutic process for Claudia. We never cease to be awed by the rich, subterranean lode of data that exists in every group and in every meeting despite the pressure to focus on the manifold external problems for which our clients seek assistance. But how to tap these unvoiced riches? Sometimes after a long silence in a meeting, a group leader might express this very thought: “There is so much information that could be valuable to us all today if only we could excavate it. I wonder if we could, each of us, tell the group about some thoughts that occurred to us in this silence, which we thought of saying but didn’t.” The exercise is more effective, incidentally, if you participate personally, even start it going. Substantial empirical evidence supports the principle that therapists who employ judicious and disciplined self-disclosure, centered in the here-and-now of the therapeutic relationship, increase their therapeutic effectiveness and facilitate clients’ exploration and openness.20 For example, you might say, “I’ve been feeling on edge in this silence, wanting to break it, not wanting to waste time, but on the other hand feeling irritated that it always has to be me doing this work for the group.” Or, “I’ve been feeling uneasy about the struggle going on in the group between you and me, Mike. I’m uncomfortable with this much tension and anger, but I don’t know yet how to help understand and resolve it.” When we feel there has been a great deal left unsaid in a meeting, we have often found the following technique useful: “It’s now six o’clock and we still have half an hour left, but I wonder if you each would imagine that the meeting has ended and that you’re on your way home. What disappointments would you have about the meeting today?” Many of the inferences the therapist makes may be off-target. But objective accuracy is not the issue: As long as you persistently direct the group from the nonrelevant, from the then-and-there, to the here-and-now, you are operationally correct. For example, if a group spends time in an unproductive meeting discussing dull, boring parties, and the therapist wonders aloud if the members are indirectly referring to the present group session, there is no way of determining with any certainty whether that is an accurate statement. Yet, by shifting the group’s attention from then-and-there to here-and-now material, the therapist performs a service to the group—a service that, consistently reinforced, will ultimately result in a cohesive, interactional atmosphere maximally conducive to therapy. Following this model, the effectiveness of an intervention should be gauged by its success in focusing the group on itself and toward the center of the room. According to this principle, the therapist who has had to cancel a meeting because of illness might ask a group that dwells at length on the general subject of health care, or on a member’s sense of guilt over remaining in bed during times of sickness, “Is the group really wondering about my recent illness?” Or a group suddenly preoccupied with death and the losses each member has incurred in his or her own life might be asked whether they are also concerned with the group’s impending four-week summer vacation. In these instances, the leader attempts to make meaningful connections between the overt content and the underlying, unexpressed group-related issues.21 Obviously, these interventions would be pointless if the group had already thoroughly worked through all the implications of the therapist’s recent absence or the impending summer break. The technical procedure is not unlike the sifting process in any traditional psychotherapy. Presented with voluminous data in considerable disarray, the therapist selects, reinforces, and interprets those aspects he or she deems most helpful to the client at that particular time. Remember that the process is overdetermined and influenced by multiple factors that are embedded one atop the other, as this example illustrates. The contemporary environment impacts clients’ emotional experience and may connect to their early life experience as well. > Political issues loomed large during this particular period of time, and understandably made their way into the group. There was a particularly intense reaction to the extant policy of separating children from their families as they crossed the border from Mexico to the United States. Group themes of “the bad guys win and get away with it,” as well as feelings of hopelessness and helpless rage, were prominent. The morale in the group was somber, almost despairing.
I (ML) encouraged the members of the group to reflect on their feelings, and Nate, a depressed man in his mid-seventies, recalled a traumatic echo from his childhood. The recent forced separations reminded him of his own parents telling him, during the McCarthy era, that they might be arrested, because they were communists and would be separated from him. He added that the anxiety provoked led to a mistrust of others and a lifelong fear of losing important relationships.
We then turned our attention to his experience with us—how did he experience the group? Was he drawing closer or distancing himself? Were there times when he felt helpless in the group? How could we best comfort and support him? How did others feel about Nate’s personal disclosure? How well were we providing what he needed from us? << Implicit here is the assumption that the therapist knows the most propitious direction for the group at a specific moment. Again, this is not a precise matter. What is most important is that the therapist has formulated broad principles of ultimately helpful directions for the group and its members, and this is where a grasp of the therapeutic factors is essential. Often, when activating the group, the therapist performs two simultaneous acts: steering the group into the here-and-now, and interrupting the content flow in the group. Not infrequently, some members will resent the interruption, and the therapist must attend to these feelings, for they, too, are part of the here-and-now. Often it is difficult for the therapist to intervene. Early in our socialization process we learn not to interrupt, and not to change the subject abruptly when in a conversation with another person or in a group. Furthermore, there are often times in the group when everyone seems keenly interested in the topic under discussion. Even though the therapist is certain that the group is not harvesting the full benefit of the session, it is not easy to buck the group current. As we’ve noted, social-psychological small-group research demonstrates the compelling power of group pressure. To take a stand opposite to the perceived consensus of the group requires considerable therapeutic courage and conviction.22 But doing so serves the therapy group twice over—both by deepening the work possible and by demonstrating that the group leader is also invested in taking risks and overcoming apprehension and anxiety. Process commentary by the therapist signals empathic attunement to the group and builds a sense of predictability, attachment security, and safety.23 Our experience is that the therapist faced with many other types of dilemmas can increase the clients’ receptivity by expressing both sets of feelings to the group. For example, “Lily, I feel very uncomfortable as you talk. I’m having a couple of strong feelings. One is that you’re into something that is very important and painful for you, and the other is that Jason [a new member] has been trying hard to participate in the group for the past few meetings, and the group seems unwelcoming. This didn’t happen when other new members joined the group. Why do you think it’s happening now?” Or, “Lenore, I’ve had two reactions as you started talking. The first is that I’m delighted you feel comfortable enough now in the group to participate, but the other is that it’s going to be hard for the group to respond to what you’re saying, because it’s very abstract and far removed from you personally. Are there some incidents or interactions that have happened here in the group, that you’ve been especially tuned in to? What reactions have you had to other members?” There are, of course, many more such activating procedures. (In Chapter 15, we describe some basic modifications in the group structure and procedure that facilitate here-and-now interaction in short-term specialized groups.) But our goal here is not to offer a compendium of techniques. Rather, we describe techniques only to illuminate the underlying principle of here-and-now activation. These group techniques, or gimmicks, are servants, not masters. To use them injudiciously, to fill voids, to jazz up the group, to acquiesce to the members’ demands that the leader lead, is seductive but not constructive for the group.24 Overall, group leader activity correlates with outcome in a curvilinear fashion—too much or too little activity leads to unsuccessful outcomes. Too little leader activity results in a floundering group. Too much activation by a leader results in a dependent group that persists in looking to the leader to supply too much. Remember that sheer acceleration of interaction is not the purpose of these techniques. The therapist who moves too quickly—using gimmicks to make interactions, emotional expression, and self-disclosure too easy—misses the whole point. Resistance, fear, guardedness, distrust—in short, everything that impedes the development of satisfying interpersonal relations—must be permitted expression. The goal is to create not a slickly functioning, streamlined social organization, but one that functions well enough and engenders sufficient trust for the unfolding of each member’s social microcosm to take place. Thus, the effective therapist doesn’t go around obstacles but works through them. Louis Ormont, one of the early modern group analysts, put it well: Though we urge clients to engage deeply in the here-and-now, we expect them to fail, to default on their contract. In fact, we want them to default because we hope, through the nature of their failure, to identify and ultimately dispel each member’s particular resistances to intimacy—including each member’s resistance style (for example, detachment, fighting, diverting, self-absorption, distrust) and each member’s underlying fears of intimacy (for example, lack of control, humiliation, abandonment, merger, vulnerability).25 We want our clients to be curious about themselves, and we need to create the conditions that promote our clients’ personal curiosity.26 TECHNIQUES OF PROCESS ILLUMINATION As soon as clients have been successfully steered into a here-and-now interactional pattern, the group therapist must attend to turning this interaction to therapeutic advantage. This task is complex and consists of several stages: • Clients must first recognize what they are doing in their interactions with other people (ranging from simple acts to complex patterns unfolding over a long time). • They must then appreciate the impact of this behavior on others and how it influences others’ opinions of them, and consequently its impact on their own self-regard. • They must decide whether they are satisfied with their habitual interpersonal style. • They must exercise the will to change. • They must transform intent into decision and decision into action. • Lastly, they must solidify the change and transfer it from the group setting into their larger life. Each of these stages may be facilitated by some specific input by the therapist, and we will describe each step in turn. First, however, we must discuss several prior considerations: How does the therapist recognize process? How can the therapist help the members assume a process orientation? How can therapists increase client receptivity to process commentary? Recognition of Process Before therapists can help clients understand process, they must themselves learn to recognize it. In other words, they must be able to reflect prior to responding in the midst of the group interaction and wonder, “Why is this unfolding in this group in this particular way and at this particular time?”27 The experienced therapist develops this skill and reliably maintains a process perspective naturally and effortlessly, observing the group proceedings from several different perspectives, including the specific individual interactions and the developmental issues in the group (which we will discuss in more depth in Chapter 10). Assuming this process perspective is a major difference in the role between the client and the therapist. Consider some clinical illustrations: > At one meeting, Elena disclosed much deep personal material. The group was moved by her account and devoted much time to listening, to helping her elaborate more fully, and to offering support. The therapist shared in these activities but entertained many other thoughts as well. For example, the therapist wondered why, of all the members, it was invariably Elena who revealed first and most. Why did Elena so often put herself in the role of the group member whom all the members must nurse? Why must she always display herself as vulnerable? And why today? And that last meeting! So much conflict! After such a meeting, one might have expected Elena to be angry. Instead, she showed her throat. Was she avoiding giving expression to her rage? << > At the end of a session in another group, Jay, a young, rather fragile young man who had been inactive in the group, revealed that he was gay and HIV positive—his first deep personal disclosure in the group. At the next meeting the group urged him to continue to describe his feelings. He attempted to do so, but, overcome with emotion, blocked and hesitated. Just then, with indecent alacrity, Vicky filled the gap, saying, “Well, if no one else is going to talk, I have a problem.” Vicky, an aggressive forty-year-old single woman who sought therapy because of social isolation and bitterness, proceeded to discuss in endless detail a complex situation involving an unwelcome visiting aunt. For the experienced, process-oriented therapist, the phrase “I have a problem” is a double entendre. Far more trenchantly than her words, Vicky’s behavior declares, “I have a problem,” and her problem is manifest in her insensitivity to Jay, who, after months of silence, had finally mustered the courage to speak. << It is not easy to tell the beginning therapist how to recognize process; the acquisition of this perspective is one of the major tasks in your education. And it is an interminable task; throughout your career, you learn to penetrate ever more deeply into the substratum of group discourse. This deeper vision increases the therapist’s interest in the meeting. Generally, beginning students who observe meetings find them far less meaningful, complex, and interesting than do experienced therapists. When we observe groups led by our trainees, for example, we have often had the experience of writing several pages of detailed notes covering a ten-minute segment of the group that our trainees might barely mention in their account during supervision of that session. Certain guidelines, though, may facilitate the neophyte therapist’s recognition of process. Note the simple nonverbal sense data available. Who chooses to sit where? Which members sit together? Who chooses to sit close to the therapist? Far away? Who sits near the door? Who comes to the meeting on time? Who is habitually late? Who looks at whom when speaking? Do some members, while speaking to another member, look at the therapist? If so, then they are relating not to one another but instead to the therapist through their speech to the others. Who looks at his watch? Who slouches in her seat? Who yawns? Do the members pull their chairs away from the center at the same time as they are verbally professing great interest in the group? How quickly do the group members enter the room? How do they leave it? Are coats kept on? When in a single meeting or in the sequence of meetings are coats removed? A change in dress or grooming not uncommonly indicates change in a client or in the atmosphere of the entire group. These sources of information are much less accessible in online groups, but attention to group process continues to be paramount in that setting as well (see Chapter 14). A large variety of postural shifts may signal discomfort; foot flexion, for example, is a particularly common sign of anxiety. Indeed, it is common knowledge that nonverbal behavior frequently expresses feelings of which a person is yet unaware. The therapist, through observing and teaching the group to observe nonverbal behavior, may hasten the process of self-exploration. Assume that every communication has meaning and salience within the individual’s interpersonal schema until proven otherwise. Make use of your own reactions to each client as a source of process data.28 Pay attention to the reactions that group members elicit in one another. Which seem to be consensual reactions shared by most, and which are unique or idiosyncratic reactions?29 Sometimes the process is clarified by attending not only to what is said but also to what is omitted: the female member who offers suggestions, advice, or feedback to the male members but never to the other women in the group; the group that never confronts or questions the therapist; the topics (for example, the taboo trio: sex, money, death) that are never broached; the individual who is never attacked; the one who is never supported; the one who never supports or inquires—all these omissions are part of the transactional process of the group. > In one group, for example, Sonia stated that she felt others disliked her. When asked who in particular disliked her, she selected Eric, a detached, aloof man who habitually related only to those who could be of use to him. Eric bristled, “Why me? Tell me one thing I’ve said to you that makes you pick me.” Sonia stated, “That’s exactly the point. You’ve never said anything to me. Not a question, not a greeting. Nothing. I just don’t exist for you. You have no use for me.” Eric, later, at a debriefing session after completing therapy, cited this incident as a particularly powerful and illuminating experience. << We may learn a great deal about the role of a particular member by observing the here-and-now process of the group when that member is absent. For example, if the absent member is aggressive and competitive, the group may feel liberated. Other members, who had felt threatened or restricted in the missing member’s presence, may suddenly blossom into activity. If, on the other hand, the group has depended on the missing member to carry the burden of self-disclosure or to coax other members into speaking, then it will feel helpless and threatened when that member is absent. Often an absence elucidates interpersonal feelings that previously were entirely out of the group members’ awareness. The therapist may then encourage the group to discuss these feelings toward the absent member both at that moment and later in his or her presence. A common myth that may need to be dispelled is that talking about a group member when that member is not present at a meeting is politically or socially incorrect. It is not “talking behind someone’s back,” and it will not lead to scapegoating, provided that the group adopts the practice of sharing the discussion with that member at the following meeting. Similarly, a rich supply of data about feelings toward the therapist often emerges in a meeting in which the therapist or a co-therapist is absent. Even if the group diminishes the importance of the absence, it is worth exploring, because doing so helps to train the group to think about itself and each relationship in the group. Does a co-leader’s absence generate group member apprehension, relief, greater risk-taking, lessened risk-taking? Your inquiry is not about your self-importance; it is about the group mindset, and it will enrich the work of therapy. > One leader led an experiential training group of mental health professionals composed of one woman and twelve men. The woman habitually took the chair closest to the door, but she felt reasonably comfortable in the group until a leaderless meeting was scheduled when the therapist was out of town. At that meeting the group discussed sexual feelings and experiences far more blatantly than ever before, and the woman had terrifying fantasies of the group locking the door and raping her. She realized how the therapist’s presence had offered her safety against fears of unrestrained sexual behavior by the other members and against the emergence of her own sexual fantasies. (She realized, too, the meaning of her occupying the seat nearest the door!) << Search in every possible way to understand the relationship messages in any communication. Look for incongruence between verbal and nonverbal behavior. Be especially curious when there is something arrhythmic about a transaction: when, for example, the intensity of a response seems disproportionate to the stimulus statement, or a response seems to be off target or to make no sense, look for possible explanations. For example, could you be witnessing parataxic distortion (where the responder experiences the sender unrealistically), or displacement (where the responder reacts not to the current transaction but to feelings stemming from previous transactions). A disproportionately strong emotional reaction—what one group member called “A Big Feeling”—may be the tip of an iceberg formed by deeper, historical concerns that get reactivated in the present.30 Common Group Tensions Remember that, to some degree, certain tensions are present in every therapy group. The group is subject to influences from within the group and its interactions, and it is also influenced by surrounding organizational, cultural, and societal forces. Some of these influences are manifest and apparent. Others are latent and obscure. Sometimes group phenomena are hiding in plain sight.31 One of the key aspects of group leadership is recognizing that multiple layers of feelings, thoughts, wishes, and fears underpin each issue or statement that emerges in the group. Things are never one-dimensional when we examine group process. Consider, for example, tensions such as the conflict between mutually supportive feelings and sibling rivalrous ones; between greed and selfless efforts to help the other; between the desire to immerse oneself in the comforting waters of the group and the fear of losing one’s precious individuality; between the wish to get better and the wish to stay in the group, between the wish that others improve and the fear of being left behind. Sometimes these tensions are quiescent for months until some event awakens them, and they erupt into plain view. Do not forget these tensions. They are omnipresent, always fueling the hidden motors of group interaction. Knowledge of these tensions often informs the therapist’s recognition of process. One of the most powerful covert sources of group tension is the struggle for dominance and status. Earlier in this chapter, we described an intervention in which the therapist, in an effort to steer a client into the here-and-now, gave her a grade for her work in the group. The intervention was effective for that particular person. Yet that was not the end of the story: there were later repercussions on the rest of the group. In the next meeting, two group members asked the therapist to clarify some seemingly positive remarks he had made to them at a previous meeting. Deeper investigation revealed that the two members, and later others, too, were requesting grades from the therapist. > In another experiential group of mental health professionals at several levels of training, the leader was much impressed by the group skills of Stewart, one of the youngest and least experienced members. The leader expressed his fantasy that Stewart was a plant—that he could not possibly be just beginning his training, since he conducted himself like a veteran with ten years’ group experience. The comment evoked a flood of tensions. It was not easily forgotten by the group and, for sessions to come, was periodically revived and angrily discussed. With his comment, the therapist placed the kiss of death on Stewart’s brow, since thereafter the group systematically challenged and undermined him. It is to be expected that the therapist’s positive evaluation of one member will evoke feelings of sibling rivalry among the others. Every step the group leader makes will be scrutinized by each member <<. The struggle for dominance, as we will discuss in more depth in Chapter 10, fluctuates in intensity throughout the group. It is much in evidence at the beginning of the group as members jockey for status and position. Once a hierarchy is established, the issue may become quiescent, with periodic flare-ups, for example, when some member, as part of his or her therapeutic work, begins to grow in assertiveness and to challenge the established order. When new members enter the group—especially aggressive members who do not respectfully search out and honor the rules of the group—you may be certain that the struggle for dominance and authority will rise to the surface. > In one group a veteran member, Cora, was much threatened by the entrance of a new, aggressive woman, Jocelyn. A few meetings later, when Cora discussed some important material concerning her inability to assert herself, Jocelyn attempted to help by commenting that she herself used to be like that, and then presenting various methods she had used to overcome it. Jocelyn reassured Cora that if she continued to talk about her lack of assertion openly in the group, she, too, would gain considerable confidence. Cora’s response was silent fury of such magnitude that several meetings passed before she could discuss and work through her feelings. To the uninformed observer, Cora’s response would appear puzzling; but in the light of Cora’s seniority in the group and Jocelyn’s vigorous challenge to that seniority, her response was entirely predictable. She was responding not to Jocelyn’s manifest offer of help, but instead to Jocelyn’s implicit communication: “I’m more advanced than you, more mature, more knowledgeable about the process of psychotherapy, and more powerful in this group despite your longer presence here.” << Primary Task and Secondary Gratification The concepts of primary task and secondary gratification, and the dynamic tension between the two, provide the therapist with a useful guide to the recognition of process (and, as we will discuss later in this chapter, a guide to the factors underlying a client’s resistance to process commentary). First, some definitions. The primary task of the client is, quite simply, to achieve his or her original goals: relief of suffering, better relationships with others, or living more productively and fully. Yet, as we examine it more closely, the task often becomes much more complicated. Generally, one’s view of the primary task changes considerably as one progresses in therapy.ii Even though their goals may evolve through the course of therapy, clients initially have some clear conception of a primary task—generally, relief of some type of discomfort. By methods discussed in Chapter 9, therapists, in pregroup preparation and in the first group meetings, make clients aware of what they must do in the group to accomplish their primary tasks. Yet once the group begins, peculiar things may occur; though clients consciously wish for change, they often avoid change and cling to old familiar modes of behavior. It is often through the recognition of resistance, a clinging to one’s familiar, albeit maladaptive approach to life, that the first real opportunity for repair and growth emerges. Some clinical vignettes illustrate this paradox: > Cal, a young man, was interested in attracting the women of the group and shaped his behavior in an effort to appear “together” and charming. He concealed his feelings of awkwardness, his desperate wish to be admired, his fear of women, and his envy of some of the men in the group. He could never discuss his compulsive masturbation and occasional voyeurism. When another male member discussed his disdain for the women in the group, Cal (purring with pleasure at the withdrawal of competition) praised him for his honesty. When another member discussed, with much anxiety, his homosexual fantasies, Cal deliberately withheld the solace he might have offered by sharing his own, similar fantasies. He never dared to discuss the issues for which he entered therapy; nothing took precedence over maintaining his image.
Another member devoted all her energies to achieving an image of mental agility and profundity. She, often in subtle ways, continually took issue with me (IY). She scorned any help I offered her and took great offense at my attempts to interpret her behavior. Finally, I reflected that working with her made me feel I had nothing of value to offer. That was her finest hour! She flashed a sunny smile as she said, “Perhaps you ought to join a therapy group to work on your problem.”
Another member enjoyed an enviable position in the group because of his girlfriend, a beautiful actress, whose picture he delighted in passing around in the group. She was his showpiece, living proof of his natural superiority. When one day she suddenly and peremptorily left him, he was too mortified to face the group and dropped out of therapy. <<
What do these examples have in common? In each, the client gave priority not to the declared primary task of personal growth and self-understanding, but to some secondary gratification arising in the group: a relationship with another member, an image a client wished to project—the most sexually desirable, the most influential, the most wise, the most superior. If this here-and-now behavior were available for study—if the members could, as it were, be pulled out of the group matrix to observe their actions in a more dispassionate manner—then the entire sequence would become part of good therapeutic work. But that did not happen! In all these instances, the gratification took precedence over the work to be done. Group members concealed information, misrepresented themselves, rejected the therapist’s help, and refused to give help to one another.
The group offers a wide range of secondary gratifications, including satisfying many social needs in an individual’s life. Moreover, the gratification offered is often compelling. Our social needs to be dominant, to be admired, to be loved, or to be revered are powerful indeed. For some, the psychotherapy group provides satisfying relationships and becomes a destination, rather than being a bridge to forming better relationships in their world at large. This presents a clinical challenge particularly with certain populations, such as the elderly, who have genuinely reduced opportunities for human connection outside of the therapy group. In such instances, offering ongoing, less frequent booster sessions, perhaps monthly, after a shorter intensive phase may be the best way to respond to the reluctance to end therapy.32
Is the tension that exists between primary task and secondary gratification nothing more than a slightly different way of referring to the familiar concept of resistance and acting out? In the sense that the pursuit of secondary gratification obstructs the therapeutic work, it may generically be labeled resistance. Yet there is an important shade of difference: Resistance ordinarily refers to pain avoidance.33 Obviously, resistance in this sense is much in evidence in group therapy, on both an individual and a group level. But what we wish to emphasize is that the therapy group offers an abundance of secondary gratifications. The therapeutic work in a group is derailed not only because members are too defensively anxious to work but also because they find themselves unwilling to relinquish certain gratifications. Groups can become defensive and passive, failing to challenge their members, as though group cohesion were to be viewed naively as an end in itself rather than a means to a therapeutic end.34
Often, when the therapist is bewildered by the course of events in the therapy group, the distinction between primary task and secondary gratification is extremely useful. It is often clarifying for therapists to ask themselves whether the client is working on his or her primary task. And when the substitution of secondary gratification for primary task is well entrenched and resists intervention, therapists have no more powerful technique than reminding the group members of the primary task—the reasons for which they seek therapy.
As a group leader, you will likely have access to much historical information and depth data about each client, but it may be an ethical breach to prod the therapy by introducing that background without the client’s consent, as the following example demonstrates:
> In exasperation, after weeks in which Joan had done no real work in the group and had thwarted each effort at engagement with her thorough evasion and denial, the group therapist blurted out to the group that nothing would progress until Joan shared with the group what she had shared with him in the assessment interview—that she was addicted to opioids. The client was outraged, felt betrayed, and filed an ethics complaint to the state board about this breach of confidentiality. <<
The same principle applies to the entire group. It can be said that the entire group has a primary task that consists of the development and exploration of all aspects of the relationship of each member to each of the others, to the therapist, and to the group as a whole. The therapist, and, later, the group members, can sense easily enough when the group is working, when it is involved in its primary task, and when it is avoiding that task.
At times the therapist may be unclear about what a group is doing but knows that it is not focused on either developing or exploring relationships between members. If therapists have provided the group with a clear statement of its primary task, then they must conclude that the group is actively evading the task—either because of some anxiety, fear, or distress associated with the task itself, or because of some secondary gratification that is sufficiently satisfying to supplant the therapy work.
The Therapist’s Feelings
All of these guides to the therapist’s recognition and understanding of process have their uses. But there is an even more important clue: the therapist’s own feelings in the meeting, feelings that he or she has come to trust after living through many similar incidents in group therapy. If therapists feel impatient, frustrated, bored, confused, discouraged—any of the panoply of feelings available to a human being—they should consider this valuable data and learn to put it to work.
Remember, this does not mean that therapists always have to understand their feelings and arrange and deliver a neat interpretive corsage. The simple expression of feelings is often sufficient to help a client proceed. A certain degree of tentativeness, coupled with genuine therapist humility, makes these process comments more accessible to the group members.35
> One therapist experienced a forty-five-year-old woman in an unreal, puzzling manner because of her rapidly fluctuating method of presenting herself. He finally commented, “Sharon, I have several feelings about you that I’d like to share. As you talk, I often experience you as a competent, mature woman, but sometimes I see you as a very young, almost preadolescent child, unaware of your sexuality, trying to cuddle, trying to be pleasing to everyone. I don’t think I can go any further with this now, but I wonder whether this has meaning for you.” The observation struck deep chords in the client and helped her explore her conflicted sexual identity and her need to be loved by everyone. <<
It is often very helpful to the group if you share feelings of being shut out by a member. Such a comment rarely evokes defensiveness, because it always implies that you wish to get closer to that person. It models important group therapy norms: risk-taking, collaboration, and taking relationships seriously.
To express such feelings in the therapeutic process, the therapist must have a reasonable degree of confidence in their appropriateness. The more you respond to the client based solely upon your personal, subjective experience (on the basis of your countertransference, or possibly because of pressing personal emotional problems), the less helpful—in fact, the more antitherapeutic—you may be in presenting these feelings as if they were the client’s problem rather than your own. You need to use the delicate instrument of your own feelings, and to do so frequently and spontaneously. But it is of the utmost importance that this instrument be as reliable and accurate as possible.
Countertransference refers broadly to the reactions therapists have to their clients. It is critically important to distinguish between your objective countertransference, reflecting on the client’s characteristic interpersonal impact on you and others, and your subjective countertransference, those idiosyncratic reactions that reflect more specifically on what you, personally, carry into your relationships from past or current shaping experiences.36 The former is an excellent source of interpersonal data about the client and grist for supervision. The latter, however, often says a good deal more about the therapist than it does about the client or group, and as such is grist for one’s own self-exploration, which may include personal psychotherapy. To discriminate between the two requires not only experience and training but also deep self-knowledge. It is for this reason that we believe every therapist should obtain personal psychotherapy. (More about this in Chapter 16.)
HELPING CLIENTS ASSUME A PROCESS ORIENTATION
It has long been known that observations, viewpoints, and insights arrived at through one’s own efforts are valued more highly than those that are thrust upon one by another person. The mature leader resists the temptation to make brilliant virtuoso interpretations, but searches instead for methods that will permit clients to achieve self-knowledge through their own efforts. As S. H. Foulkes and E. J. Anthony put it, “there are times when the therapist must sit on his wisdom, must tolerate defective knowledge and wait for the group to arrive at solutions.”37
The task, then, is to influence members to assume and to value the process perspective. Many of the norm-setting activities of the leader described in Chapter 5 serve this end. For example, the therapist emphasizes process by periodically tugging the members out of the here-and-now and inviting them to consider more dispassionately the meaning of recent transactions. Though techniques vary depending on a therapist’s style and therapy model, the intention of these interventions is to switch on a self-reflective beacon. Process commentary generates an immediacy that makes the treatment come alive.38
The therapist may, for example, interrupt the group at an appropriate point to comment, in effect, “We are about halfway through our time for today, and I wonder how everyone feels about the meeting thus far?” Again, by no means do you have to understand the process to ask for members’ analyses. You might simply say, “I’m not sure what’s happening in the meeting, but I do see some unusual things. For example, Bill has been unusually silent, Jack’s moved his chair back, Mary’s been shooting glances at me for the past several minutes. What ideas do you all have about what’s going on today?”
A process review of a highly charged meeting is often necessary. It is important for the therapist to demonstrate that intense emotional expression provides material for significant learning. Sometimes you can divide such a meeting into two parts: the experiential segment and the analysis of that experience. At other times you may analyze the process at the following meeting; you can ask about the feelings that members took home with them after the previous meeting, or simply solicit further thoughts they have since had about what occurred there.
Obviously, you teach through modeling your own process orientation. There is generally nothing to lose and much to gain by your sharing your perspective on the group whenever possible. But stay alert to the alignment of your impact and desired intent. Don’t assume they always match up as you expect them to do, and check regularly about the group’s reactions to your efforts. Sometimes you may do this in an effort to clarify the meeting: “Here are some of the things I’ve seen going on today.” Sometimes you may wish to use a convenient device, such as summarizing the meeting to a late arrival, whether co-therapist or member. One technique that systematically shares process observations with members is to write a detailed summary immediately after the meeting, including a full description of the therapist’s spoken and unspoken process observations, and to mail it to the members before the next meeting. With this approach the therapist uses considerable personal and professional disclosure in a way that facilitates the therapy work, particularly by increasing the members’ perceptivity to the process of the group. We will discuss these techniques in more depth in Chapter 13.
It is useful to encourage members to describe their views on the process of group meetings. Many group therapy instructors who teach by leading an experiential group of their students often begin each meeting with a report, prepared by a designated student, of the process of the previous meeting. Some therapists learn to call upon certain members who display unusual intuitive ability to recognize process. For example, Louis Ormont described a peripheral member in his group who had unusual sensitivity to the body language of others. He made a point of harnessing that talent for the service of therapy. A question such as, “Michael, what was Pam saying to Abner with that wave of her hand?” served a double purpose: illumination of process and helping Michael gain centrality and respect.39
HELPING CLIENTS ACCEPT PROCESS-ILLUMINATING COMMENTS
Throughout therapy, we ask our clients to examine the consequences of their behavior. It is hard work, and it is often unpleasant, frightening work. It is not enough simply to provide clients with information or explanations; you must also facilitate the assimilation of the new information. There are strategies to help clients in this work.
Be concerned with the framing of interpretive remarks and feedback. No comments, not even the most brilliant ones, can be of value if their delivery is not accepted, if the client rejects the package unopened and uninspected. The relationship, the style of delivery, and the timing are thus as essential as the content of the message. Although we are highlighting technical steps in the process of change in this section with a heavy emphasis on the client’s responsibility, our therapeutic effectiveness is tied to establishing and maintaining an environment that is collaborative and maximizes the client’s sense of attachment security and safety. Nothing productive will emerge without the creation of that healing context.40
Clients are always more receptive to observations that are framed in a supportive and nonblaming fashion. Rarely do individuals reject an observation that they shut out others, or that they are too unselfish and never ask for anything for themselves, or that they are stingy with their feelings, or that they conceal much of what they have to offer. All of these observations contain a supportive message: that the member has much to give and that the observer wishes to be closer, wishes to help, wishes to know the other more intimately. If you come to understand something only after the session, don’t hesitate to say so. It can be of great impact to say in the next group, “I wish I understood then what I understand now. I would have approached this issue differently. I hope we can continue to discuss this.” It is an interesting phenomenon in training that we spend so much time learning to understand our clients and less time learning how best to communicate that understanding effectively to them.41
Beware of comments that are categorizing or limiting: they are counterproductive; they threaten; they raise defenses. Clients reject global accusations—for example, of dependency, narcissism, exploitation, or arrogance—and with good reason, since a person is always more than any label or combination of labels. It is far more acceptable (and true) to speak of traits or parts of an individual—for example, “I often can sense you very much wanting to be close to others, offering help as you did last week to Debbie. But there are other times, like today, when I see you as aloof, almost scornful of the others. What do you know about this part of you?” Always avoid using the word always and never use the word never in describing clients’ behavior or impact. Stay honest, but try to maximize the clients’ openness to your feedback.
Often in the midst of intense group conflict, members hurl important truths at one another. Under these conditions, one cannot acknowledge the truth: it would be aiding the aggressor, committing treason against oneself. To make the conflict-spawned truths available for consumption, the therapist must appreciate and neutralize the defensiveness of the combatants.
You may, for example, appeal to a higher cause (the member’s desire for self-knowledge), or increase receptivity by limiting the scope of the accusation. For example, “Farrell, I see you now closed up, threatened, and fending off everything that Jamie is saying. You’ve been very adroit in pointing out the weaknesses of her arguments. But what happens is that you (and Jamie, too) end up getting nothing for yourself. I wonder if you could take a different tack for a while and ask yourself this [and, later, “Jamie, I’d like to ask you to do the same”]: Is there anything in what Jamie is saying that is true for you? What parts seem to strike an inner chord? Could you forget for a moment the things that are not true and stay with those that are true?”
Sometimes group members, in an unusually open moment, make a statement that may at some future time provide the therapist with great leverage. The adept therapist underscores these comments in the group and stores them for later use. For example, one man, who was both proud of and troubled by his ability to manipulate the group with his social charm, pleaded at one meeting, “Listen, when you see me smile like this, I’m really hurting inside. Don’t let me keep getting away with it.” Another member, who tyrannized the group with her tears, announced one day, “When I cry like this, I’m angry. I’m not going to fall apart, so stop comforting me, stop treating me like a child.” Be sure to store these moments of truth; they can be of great value if recalled later, in a constructive, supportive manner, when the client is closed and defensive.
Often it is useful to enlist the client more actively in establishing contracts. For example, if a client has worked hard in a session on some important trait, you might say something like, “Jane, you worked hard today and were very open to our feedback about the way you mother others and avoid facing your own needs and pain. How did it feel? Did we push you too hard?” If the client agrees that the work was helpful (as the client almost always does), then it is possible to nail down a future contract by asking, “Then is it all right for us to keep pressing you, to give you feedback whenever we note you doing this in future meetings?” This form of “contracting” consolidates the therapeutic alliance.42
PROCESS COMMENTARY: A THEORETICAL OVERVIEW
It is not easy to discuss, in a systematic way, the actual practice of process illumination. How can one propose crisp, basic guidelines for a procedure of such complexity and range, such delicate timing, so many linguistic nuances? We are tempted to beg the question by claiming that herein lies the art of psychotherapy: it will come as you gain experience; you cannot, in a systematic way, come to it. To a degree, this is accurate. Yet we also believe that it is possible to blaze crude trails, to provide the clinician with general principles that will accelerate education without limiting artistry.
The approach we take in this section closely parallels the approach we used in the beginning of this book to clarify the basic therapeutic factors in group therapy. At that time, we asked the questions: “How does group therapy help clients? In the group therapeutic process, what is core and what is front?” We proceed now in a similar fashion. Here the issue is not how group therapy helps but how process illumination leads to change. The issue is complex and requires considerable attention, but the length of this discussion should not suggest that the interpretive function of the therapist take precedence over other tasks.
First, let us proceed to view in a dispassionate manner the entire range of therapist interventions. We ask of each intervention a simplistic but basic question, “How does this intervention, this process-illuminating comment, help a client to change?” Underlying this approach is a set of basic operational patterns shared by many contemporary interpersonal and relational models of therapy.43
Let’s begin by considering a series of process comments that a group therapist made to a male client who sought therapy to address his social isolation. Here are comments from several sessions of group therapy:
1. You are interrupting me.
2. Your voice is tight, and your fists are clenched.
3. Whenever you talk to me, you take issue with me.
4. When you do that, I feel threatened and sometimes frightened.
5. I wonder if you don’t feel competitive with me and are trying to devalue me.
I’ve noticed that you’ve done the same thing with the men in the group. Even when they try to approach you helpfully, you strike out at them. Consequently, they see you as hostile and threatening.
7. In the three meetings when there were no women present in the group, you were more approachable.
8. I think you’re so concerned about your sexual attractiveness to women that you view men only as competitors and deprive yourself of the opportunity of ever getting close to a man.
9. Even though you always seem to spar with me, there seems to be another side to it. You often stay after the group to have a word with me; you frequently look at me in the group. And there’s that dream you described three weeks ago about the two of us fighting and then falling to the ground in an embrace. I think you very much want to be close to me, but somehow you’ve got closeness and eroticism entangled and you keep pushing me away.
10. You are lonely here and feel unwanted and uncared for. That rekindles so many of your feelings of unworthiness.
11. I remember that one of your major goals when you started the group was to find out why you haven’t had any close male friends and to do something about that, but what’s happened in the group now is that you’ve distanced yourself, estranged yourself, from all the men here. What are your feelings about that?
Note, first of all, that the comments form a progression: they start with simple observations of single acts and proceed to a description of feelings evoked by an act, to observations about several acts over a period of time, to the juxtaposition of different acts, to speculations about the client’s intentions and motivations, to comments about the unfortunate repercussions of his behavior, to the inclusion of more inferential data (dreams, subtle gestures), to calling attention to the similarity between the client’s behavioral patterns in the here-and-now and in his outside social world. Inexperienced group therapists sometimes feel lost because they have not yet developed an awareness of this progressive sequence of interventions. If we use only the more charged and higher inferential statements, we may force the client into a polarized stance and compromise the collaborative nature of therapy.44
Note that in this progression, the comments become more inferential. They begin with observations and gradually shift to complex statements based on sequences of behavior, interpersonal patterns, fantasy, and dream material. As the comments become more complex and more inferential, their author becomes more removed from the other person—in short, more a therapist process-commentator. Members often make some of the earlier statements to one another, but, for reasons we have already presented, they rarely make the ones at the end of the sequence.
There is, incidentally, an exceptionally sharp barrier between comments 4 and 5. The first four statements issue from the experience of the commentator. They are the commentator’s observations and feelings; the client can devalue or ignore them but cannot deny them, disagree with them, or take them away from the commentator. The fifth statement (“I wonder if you don’t feel competitive with me and are trying to devalue me”) is much more likely to evoke defensiveness and to close down constructive interactional flow. This genre of comment is intrusive; it is a guess about the other’s intention and motivation and is often rejected unless a trusting, supportive relationship has been previously established. If members in a young group make many comments of this type to one another, they are not likely to develop a constructive therapeutic climate.45 Using the phrase “I wonder” of course softens it a bit. (Where would we therapists be without the use of “I wonder”?) At no point is the feedback devaluing or critical of the person as a whole: behavior, not personhood, is the focus.
But back again to our basic question: How does this series (or any series) of process comments help the client change? The answer is that the group therapist initiates change by escorting the client through the following sequence:
1. Here is what your behavior is like. Through feedback and later through self-observation, members learn to see themselves as seen by others. This is a key step in the understanding of how the client’s pathogenic beliefs shape his interpersonal behavior.
2. Here is how your behavior makes others feel. Members learn about the impact of their behavior on the feelings of other members.
3. Here is how your behavior influences the opinions others have of you. Members learn that, as a result of their behavior, others value them, dislike them, find them unpleasant, respect them, avoid them, and so on.
4. Here is how your behavior influences your opinion of yourself. Building on the information gathered in the first three steps, clients formulate self-evaluations; they make judgments about their self-worth and their lovability. (Recall Harry Stack Sullivan’s keen aphorism that the self-concept is largely constructed from reflected self-appraisals.)
Once this sequence is fully understood by the individual, once clients have a deep understanding that their behavior is not in their own best interests, that the texture of relationships to others and to themselves is fashioned by their own actions rooted in their long-held beliefs and assumptions, then they have come to a crucial point in therapy: they have entered the antechamber of change. Considerable research underscores that what unfolds is a circular process of change, with interpersonal exploration followed by a period of consolidation and retreat to safety, in turn followed by more interpersonal exploration.46
The therapist is now in a position to pose a question that initiates the real crunch of therapy. The question, presented in a number of ways by the therapist but rarely in direct form, is: This is what you do to others, to others’ opinions of you, and to your opinion of yourself—Are you satisfied with your actions and the world you have created?47
When the inevitable negative answer arrives (“No, I am not satisfied with my actions”), the therapist embarks on a many-layered effort to transform a sense of personal dissatisfaction into a decision to change and then into the act of change. In one way or another, the therapist’s interpretive remarks are designed to encourage the act of change. Only a few psychotherapy theoreticians—for example, Otto Rank, Rollo May, Silvano Arieti, Stephen Mitchell, and Leslie Farber48—include the concept of will in their formulations, yet it is implicit in most interpretive systems. I (IY) offer a detailed discussion of the role of will in psychotherapy in my text Existential Psychotherapy.49 For now, broad brushstrokes are sufficient.
The intrapsychic agency that initiates an act, that transforms intention and decision into action, is will. Will is the primary responsible mover within the individual. Although analytic metapsychology historically chose to emphasize unconscious motivations and drives as the movers of our behavior, it is difficult to do without the idea of will in our understanding of change.50 We cannot bypass it under the assumption that it is too nebulous and too elusive and, consequently, consign it to the black box of the mental apparatus to which the therapist has no access.
Relational models recognize the role of will more fully. Mitchell cautioned that attention to the role of client will and choice is essential; without it, therapy can devolve into intellectual explanation and rationalization. Relationships involve personal authorship and choice, which in turn entail the role of one’s creative will.51 Group therapy teaches members that they have the agency to repeat patterns or to create new ones. Little is neutral; our clients’ choices are either moving them ahead or perpetuating the status quo.
Knowingly or unknowingly, most therapists assume that each client possesses the capacity to change through willful choice. Using a variety of strategies and tactics, the therapist attempts to escort the client to a crossroads where he or she can choose, willfully, in the best interests of his or her own integrity. The therapist’s task is not to create will or to infuse it into the client. That, of course, you cannot do. What you can do is to help remove encumbrances from the bound or stifled will of the client and enhance the client’s motivation to change.52
The concept of will provides a useful construct for understanding the procedure of process illumination. The interpretive remarks of the therapist can all be viewed in terms of how they bear on the client’s will. The most common, most simplistic, and least effective therapeutic approach is exhortative: “Your behavior is, as you yourself now know, counter to your best interests. You are not satisfied. This is not what you want for yourself. Damn it, change!”
However, clients with significant and well-entrenched psychopathology will need much more than sheer exhortation. The therapist, through interpretative comments, then proceeds to help clients liberate their will and accept one, several, or all of the following basic premises:
1. Only I can change the world I have created for myself.
2. There is no danger in change.
3. To attain what I really want, I must change.
4. I can change; I am potent.
Each of these premises, if fully accepted by a client, can be a powerful stimulant to willful action. Each exerts its influence in a different way. Though we will discuss each in turn, we do not wish to imply a sequential pattern. Each, depending on the need of the client and the style of the therapist, may be effective independently of the others. All contribute to the development of self-efficacy and a sense of effectiveness in one’s interpersonal world.53
“Only I can change the world I have created for myself.”
Behind the simple group therapy sequence we have described (seeing one’s own behavior and appreciating its impact on others and on oneself), there is a mighty overarching concept, one whose shadow touches every part of the therapeutic process. That concept is responsibility. Although it is rarely discussed explicitly, it is woven into the fabric of most psychotherapeutic systems. Responsibility has many meanings—legal, religious, ethical. We use it in the sense that a person is “responsible for,” by being the “basis of,” the “cause of,” or the “author of” something.
One of the most fascinating aspects of group therapy is that everyone is born again, born together in the group. In other words, each member starts off on an equal footing. In the view of the others (and, if the therapist does a good job, in their own views of themselves), each member gradually scoops out and shapes a life space in the group. Each one, in the deepest sense of the concept, is responsible for this space and for the sequence of events that will occur to him or her in the group.
The therapist helps the client understand that the interpersonal world is arranged in a generally predictable and orderly fashion; that it is not that the client cannot change, but that he or she will not change; that the client bears the responsibility for the creation of his or her world, and therefore the responsibility for its transmutation. The client must regain or develop anew a sense of interpersonal agency in the world. Early life experience may have squashed or undermined that capacity, but it can be reclaimed and redeveloped. Group members regularly report that they are inspired to action by seeing others take risks, or they feel accountable, knowing the group will ask whether an undertaking discussed in the group was completed. Whenever possible, we highlight the personal choices group members make in relating to others and addressing issues.
One group member with a history of chronic depression and social anxiety reported that after her boyfriend commented she was socially anxious, she felt like a victim and withdrew. (She had ended relationships over lesser affronts.) This time, she declared to the group, she decided to work from her increasing strengths and tell him she was now committed to overcoming her avoidance. She then worked through in the group how choosing this course, rather than the path she would have taken in the past, impacted her sense of self and improved her relationship with her boyfriend.
“There is no danger in change.”
These well-intentioned efforts may not be enough. The therapist may tug and tug at the therapeutic cord and learn that individuals, even after being thus enlightened, still make no significant therapeutic movement. In this case, therapists apply additional therapeutic leverage by helping clients face the paradox of continuing to act contrary to their basic interests. In a number of ways therapists must pose the question, “How come you continue to defeat yourself?”
A common method of explaining “How come?” is to assume that there are formidable obstacles to the client’s exercising willful choice, obstacles that prevent clients from seriously considering altering their behavior. The presence of the obstacle is generally inferred; the therapist makes an “as if” assumption: “You behave as if you feel some considerable danger would befall you if you were to change.” The therapist helps the client clarify the nature of the imagined danger and then proceeds, in several ways, to detoxify and disconfirm the reality of this danger.
The client’s reason may be enlisted as an ally. The process of identifying and naming the fantasized danger may, in itself, enable one to understand how far removed one’s fears are from reality. Another approach is to encourage the client, in carefully calibrated doses, to commit the feared act in the group. The fantasized calamity does not, of course, ensue, and the dread is gradually extinguished. This is often the pivotal piece of effective therapy. Change is probably not possible, let alone enduring, without the client’s having a lived experience of direct disconfirmation of pathogenic beliefs. Insight alone is unlikely to be effective.
For example, suppose a client avoids any aggressive behavior because at a deep level he fears that he has a dammed-up reservoir of homicidal fury and must be constantly vigilant, lest he unleash it and face retribution from others. An appropriate therapeutic strategy is to help the client express aggression in small doses in the group: pique at being interrupted, irritation at members who are habitually late, anger at the therapist for charging him money, and so on. Gradually, the client is helped to relate openly to the other members and to demythologize himself as a destructive being. Although the language and the view of human nature are different, this is precisely the same approach to change used in systematic desensitization—a major technique of behavior therapy.
“To attain what I really want, I must change.”
Another explanatory approach used by many therapists to deal with clients who persist in behaving counter to their own best interests is to consider the payoffs of their behavior. Although their behavior sabotages many of their mature needs and goals, it may at the same time satisfy another set of needs and goals that cannot be simultaneously satisfied. For example, a client may wish to establish mature intimate sexual relationships; but at another, often unconscious, level, may wish to be nurtured, to be cradled endlessly, to avoid the abandonment anticipated as the punishment for adult strivings, or, to use an existential vocabulary, to be sheltered from the terrifying freedom of adulthood. Obviously, the client cannot satisfy both sets of wishes: to establish an adult sexual relationship with another adult, while also saying (and much more loudly), “Take care of me, protect me, nurse me, let me be a part of you.”
It is important to clarify this paradox empathically and without blaming clients. We might, for example, point out, “Your behavior makes sense if we assume that you wish to satisfy the deeper, earlier, more primitive need.” We try to help the client understand the nature of these conflicting desires and to choose between them; to relinquish those that cannot be fulfilled except at enormous cost to personal integrity and autonomy. Once clients realize what they really want as adults, and that their behavior is designed instead to fulfill opposing, growth-inhibiting needs, they gradually come to a logical conclusion: To attain what I really want, I must change.
“I can change; I am potent.”
Perhaps the major therapeutic approach to the question “How come you act in ways counter to your best interests?” is to offer explanation. The therapist says, in effect, “You behave in certain fashions because…” and the “because” clause generally involves motivational factors outside the client’s awareness. It is true that the previous two options we have discussed also proffer explanation but—and we will clarify this shortly—the purpose of the explanation (the nature of the leverage exerted on will) is quite different in the two approaches.
What type of explanation does the therapist offer the client? And which explanations are correct, and which incorrect? Which are “deep”? Which are “superficial”? It is at this juncture that the great metapsychological controversies of the field arise, since the nature of therapists’ explanations are a function of the ideological school to which they belong, and our ideology may narrow our vision and restrict our understanding. It may even serve as a therapist’s defense against clinical complexity.54
I think we can sidestep the ideological struggle by keeping a fixed gaze on the function of the interpretation, on the relationship between explanation and the final product: change. After all, our goal is change. Self-knowledge, derepression, analysis of transference, and self-actualization—all are worthwhile, enlightened pursuits, all are related to change, preludes to change, cousins and companions to change—and yet they are not synonymous with change.
Explanation provides a system by which we can order the events in our lives into some coherent and predictable pattern. To name something and to place it into a causal sequence is to experience it as being under our control. No longer is our behavior or our internal experience frightening, inchoate, out of control; instead, we behave (or have a particular inner experience) because… It offers us freedom, mastery, and self-efficacy. As we move from a position of being motivated by unknown forces to a position of identifying and controlling those forces, we move from a passive, reactive posture to an active, acting, changing posture.
If we accept this basic premise—that a major function of explanation in psychotherapy is to provide the client with a sense of personal mastery—it follows that the value of an explanation should be measured by this criterion. To the extent that it offers a sense of potency, a causal explanation is valid, correct, or “true.” Such a definition of truth is completely relativistic and pragmatic. It argues that no explanatory system has hegemony or exclusive rights, that no system is the correct, fundamental one, or the “deeper” (and therefore better) one.
Therapists may offer the client any of several interpretations to clarify the same issue; each may be made from a different frame of reference, and each may be “true.” Freudian, interpersonal, transcultural, feminist, object relation, self-psychology, attachment theory, existential, transactional analytic, Jungian, gestalt, transpersonal, cognitive, and behavioral explanations—all of these may be true simultaneously. None, despite vehement claims to the contrary, have sole rights to the truth. They justify their existence only by virtue of their explanatory powers.55
Do we therefore abandon our attempts to make precise, thoughtful interpretations? Not at all. We only recognize the purpose and function of the interpretation. Some may be superior to others not because they are deeper, but because they have more explanatory power, are more credible, provide more mastery, and are therefore more useful. Obviously, interpretations must be tailored to the recipient. In general, therapeutic interventions are more effective if they make sense, if they are logically consistent with sound supporting arguments, if they are bolstered by empirical observation, if they “feel” right or are congruent and “click” with a client’s frame of reference, culture, and internal world, and if they can be generalized and applied to many analogous situations in the client’s life.56 They can become self-reinforcing as clients realize that addressing interpersonal issues helps to improve depression and emotional distress.57
Psychoanalytic revisionists argue that reconstructive attempts to capture historical “truth” are futile; it is far more important to the process of change to construct plausible, meaningful personal narratives.58 The past is not static: every experienced therapist knows that the process of exploration and understanding alters the recollection of the past. Moreover, our clients’ early and shaping emotional experiences are often stored as implicit memories and cannot be reached by appealing to explicit memory: they can only be accessed and worked through the relationship and the interactional focus in therapy.59
Do not always expect the client to accept your intervention. Sometimes the client hears the same statement many times until one day it seems to “click.” Why does it click that one day? Perhaps the client just came across some corroborating data from new events in the environment or from the surfacing in fantasy or dreams of some previously unconscious material. Note also that your intervention will not click until the client’s relationship with you is just right. A group member who feels unsafe, threatened, or competitive with the therapist is unlikely to be helped by any interpretation (except perhaps one that clarifies the transference).60 Even the most seemingly thoughtful interpretation will fail because the client may feel defeated or humiliated by the proof of the therapist’s superior insight. An interpretation becomes maximally effective only when it is delivered in a context of acceptance and trust.
Sometimes a client will accept from another member an interpretation that he or she would not accept from the therapist. (Remember, group members are entirely capable of making interpretations as useful as those of the therapist provided the other member has accepted the client role and does not offer interpretations to acquire prestige, power, or a favored position with the leader.)
A comprehensive discussion of the types of effective interpretations would require describing the vast number of explanatory schools and group therapy models—a task well beyond the scope of this book.61 However, three venerable concepts are so deeply associated with interpretation that they deserve coverage here:
1. The use of the past
2. Group-as-a-whole process commentary
3. Transference
We will discuss the first two in the remainder of this chapter. We devote the next chapter entirely to the issue of transference and transparency.
THE USE OF THE PAST
Too often, explanation is confused with “originology” (the study of origins). Although, as we have discussed, an explanatory system may effectively postulate a “cause” of behavior from any of a large number of perspectives, many therapists continue to believe that the “real,” the “deepest,” causes of behavior are only to be found in the past.62 Yet, by no means are the powerful and unconscious factors that influence human behavior limited to the past. Analytic theory makes a distinction between the past unconscious (the child within the adult) and the present unconscious (the currently existing unconscious thoughts, fantasies, and impulses that influence our feelings and actions).63
Furthermore, the future is also a significant determinant of behavior, and the concept of future determinism is fully defensible. We have at all times within us a sense of purpose, an idealized self, a series of goals for which we strive, a death toward which we travel. Certainly, the knowledge of our isolation, our destiny, and our ultimate death deeply influences our conduct and our inner experience. Though we generally keep them out of awareness, the terrifying contingencies of our existence play upon us without end. We either strive to dismiss them, by enveloping ourselves in life’s many diversions, or we attempt to vanquish death by faith in an afterlife, or by striving for symbolic immortality in the form of children, material monuments, and creative expression. In addition to the explanatory potency of the past and the future, there is a third temporal concept that attempts to explain behavior—the impact of current forces.
In summary, explanations ensue from the exploration of the concentric rings of conscious and unconscious current motivations that envelop our clients. Take one example: clients may have a need to attack that covers a layer of dependency wishes that they do not express for fear of rejection. Note that we need not ask how they got to be so dependent. In fact, the future (a person’s anticipation of rejection) plays a more central role in the explanation. Thus, as we hurtle through space, our behavioral trajectory may be thought of as triply influenced: by the past—the nature and direction of the original push; by the future—the goal that beckons us; and by the present—the ways in which clients repeat unhealthy relationship patterns. Consider this clinical example:
> Two clients, Ellen and Carol, expressed strong sexual feelings toward the male therapist of the group. (Both women, incidentally, had histories of early abuse and sexual trauma, both in their past and in recent relationships.) At one meeting, they discussed the explicit content of their fantasies of longing regarding the therapist. Ellen fantasized about her husband being killed; herself having a psychotic breakdown; and the therapist hospitalizing her and personally nurturing her, rocking her, and caring for all her bodily needs. Carol had a different set of fantasies. She wondered whether the therapist was well cared for at home. She frequently fantasized that something happened to his wife and that she would care for him by cleaning his house and cooking his meals.
The manifestly shared sexual attraction (which, as the fantasies indicate, was not actually sexual) that Ellen and Carol articulated had very different explanations. The therapist pointed out to Ellen that throughout the course of the group, she had suffered frequent physical illness or severe psychological relapses. He wondered whether, at a deep level, she felt as though she could get his love and that of the other members only by a form of self-immolation. If this were the case, however, it never worked. More often than not, she discouraged and frustrated others. Even more important was the fact that as long as she behaved in ways that caused her so much shame, she could not love herself. He emphasized how that hampered her therapy: she was afraid to get better, because she felt that to do so would entail an inevitable loss of love and nurturance.
In his comments to Carol, the therapist juxtaposed several aspects of her behavior: her self-derogation, her refusal to assume her rights, her inability to get men interested in her. Her fantasy of taking care of the therapist was illustrative of her motivations: she believed that if she could be self-sacrificing enough, if she could put the therapist deeply into her debt, then she should, in reciprocal fashion, receive the love she sought. However, Carol’s search for love, like Ellen’s, always failed. Her dread of self-assertion and her continued self-devaluation succeeded only in making her appear dull and spiritless to those whose regard she most desired. Carol, like Ellen, whirled about in a vicious circle of her own creation: the more she failed to obtain love, the more frantically she repeated the same self-destructive pattern—the only course of behavior she knew of or dared to enact. << So here we have two clients with a similar behavioral pattern: “sexual” infatuation with the therapist. Yet the therapist offered two different interpretations reflecting two different dynamic pathways to psychological suffering. In each, the therapist assembled several aspects of the client’s behavior in the group as well as fantasy material and suggested that, if certain “as if” assumptions were made (for example, that Ellen acted as if she could obtain the therapist’s love only by offering herself as severely damaged, and that Carol acted as if she could obtain his love only by serving him and thus placing him in her debt), then the rest of the behavior “made sense.” Both interpretations were potent and had a significant impact on future behavior. Yet neither broached the question “How did you get to be that way? What happened in your earlier life to create such a pattern?” Durable and meaningful change ensued without much historical exploration. The past cannot be altered—only the present and future can be. Both dealt instead with currently existing patterns: the desire for love, the conviction that it could be obtained only in certain ways, the sacrifice of autonomy, the consequent shame, the ensuing increased need for a sign of love, and so on. One formidable problem with explanations based on the distant past is that they contain within them the seeds of therapeutic despair. Thus the paradox: if we are fully determined by the past, whence comes the ability to change? The past, however, no more determines the present and the future than it is determined by them. The past exists for each of us only as we constitute it in the present against the horizon of the future. Jerome Frank, a pioneer in exploring what makes psychotherapy effective, reminded us that clients, even in prolonged therapy, recall only a minute fraction of their past experience, and they may selectively recall and synthesize the past so as to achieve consistency with their present view of themselves.64 In the same way that a client (as a result of therapy) alters her self-image, she may reconstitute the past. She may, for example, recall long-forgotten positive experiences with her parents; she may humanize them and forgive them, and begin to understand them as harried, well-intentioned individuals struggling with the same overwhelming facts of the human condition that she faces herself. Once she reconstitutes the past, a new past can further influence her self-appraisal. Indeed, it may be the reconstitution, not simply the excavation, of the past that is crucial. Note an allied research finding: effective therapy generates further recollection of past memories that may have shaped the individual’s fundamental view of self and others, which in turn further modify the reconstitution of the past.65 If explanations are not to be sought from excavating the past, and if the most potent focus of the group is the ahistorical here-and-now, does the past therefore play no role at all in the group therapeutic process? By no means! The past is an incessant visitor to the group and an even more incessant visitor to the inner world of each of the members during the course of therapy. Not infrequently, for example, a discussion of the past plays an important role in the development of group cohesiveness by increasing intermember understanding and acceptance. But even groups that focus on life review or reminiscing therapy—for example, in geriatric populations—are enhanced by then turning attention to the here-and-now of the experience of sharing and recollecting together; of being known more fully by the other members.66 The past is often invaluable in conflict resolution through the generation of compassion and mentalization. A man with a regal air of condescension may suddenly seem understandable and approachable when we learn of his immigrant parents, and his desperate struggle to transcend the degradation of an impoverished inner-city childhood. Individuals benefit through being fully known by others in the group and being fully accepted. An ahistorical here-and-now interactional focus is never fully attainable. Discussions of future anticipations, both feared and desired, and of past and current experiences are an inextricable part of human discourse. What is important in group therapy is the emphasis: the past is the servant, not the master; it explicates the current reality of the client, who is in the process of unfolding in relation to the other group members. As one prominent psychotherapist stated, “It makes better sense to say that the analyst makes excursions into historical research in order to understand something which is interfering with his present communication with the patient (in the same way that a translator might turn to history to elucidate an obscure text) than to say that he makes contact with the patient in order to gain access to biographical data.”67 To employ the past in this manner involves an anamnestic technique differing from that often employed in individual therapy. Rather than a careful global historical survey, group therapists periodically attempt a sector analysis, in which they explore the development of some particular interpersonal stance. Consequently, many other aspects of a client’s past remain undiscussed in group therapy. Often group therapists conclude a course of successful therapy with a client and yet be unfamiliar with many significant aspects of the individual’s early life. At the end of therapy, clients commonly report significant attitudinal improvements in relationships that have not been discussed in the group. Many of these involve family relationships stretching far back into the past. Many clients, in fact, change their feelings about family members who are long dead. So the past plays a role in the working-through process, albeit an implicit role. To make repetitive use of the group meeting for explicit discussion of the past would sacrifice the therapeutic potency of the here-and-now interactional focus. GROUP-AS-A-WHOLE PROCESS COMMENTARY Some group leaders choose to focus heavily on group-as-a-whole phenomena and frequently refer to the “group,” or “we,” or “all of us.” They attempt to clarify the relationship between the group and its primary task, or between the group and the leader or one of its members, or the group and a subgroup of members, or to elicit examination of some shared group-centered concern. Recall, for a moment, the “parenthood is degrading” incident described earlier in this chapter. In that incident, the therapist had many process commentary options, some of which were group-as-a-whole explanations. He might, for example, have raised the issue of whether the “group” needed a scapegoat, and whether, with Kate gone, Burt filled the scapegoat role; or whether the “group” was actively avoiding an important issue—that is, the members’ guilty pleasure and fears about Kate’s departure. Throughout this text we weave in comments related to group-as-a-whole phenomena. Examples include norm setting, the role of the deviant, scapegoating, emotional contagion, role suction, subgroup formation, group cohesiveness, group pressure, the regressive dependency fostered by group membership, and the group’s response to termination, to the addition of new members, to the absence of the leader, and so on. In addition to these common group phenomena, earlier editions of this book described some comprehensive group-as-a-whole approaches, particularly the work of Wilfred Bion, which offers an elaborate description of the psychology of groups and the unconscious forces that obstruct effective group functioning.iii His approach, also known as the Tavistock approach, persists as a useful model for understanding group-as-a-whole dynamics and the psychology of organizational life. Its emphasis, however, on an inscrutable, detached leader who serves as “conductor” of the group, and who limits participation solely to group-as-a-whole interpretations, has not proved to be clinically effective. As a result, the traditional Tavistock approach for clinical group psychotherapy has virtually been abandoned.68 Tavistock conferences, however, are still used as an educational vehicle to inform participants about the nature of group forces, leadership, and authority. There is little question of the importance of group-as-a-whole phenomena. All group leaders would agree that inherent forces in a group significantly influence behavior; individuals behave differently in a group than they do in dyads (a factor that, as we will discuss in Chapter 8, complicates the selection of group therapy members). There is wide agreement that an individual’s behavior cannot be fully understood without an appreciation of his or her social and environmental context. But there remains the question of how best to apply this knowledge in the course of the therapy group. Examining the rationale of group-as-a-whole commentary provides some guidelines. Rationale of Group-as-a-Whole Process Commentary Group-as-a-whole phenomena influence the clinical course of the group in two significant ways: they can act in the service of the group or they can impede effective group therapy. Group-as-a-whole forces acting in the service of therapy. We have, throughout this text, already considered many therapeutic uses of group-as-a-whole phenomena: for example, many of the major therapeutic factors, such as cohesiveness—the esprit de corps of the entire group—obviously relate to group-as-a-whole properties, and therapists are, in fact, harnessing group-as-a-whole forces when they facilitate the development of cohesiveness. However, it does not follow that the leader must make explicit group-as-a-whole comments. Group-as-a-whole forces impeding therapy. There are times when group-as-a-whole processes significantly impede therapy, and then commentary is necessary. In other words, the purpose of a group-as-a-whole interpretation is to remove some obstacle that has arisen that obstructs the progress of the entire group.69 The two most common types of obstacles are anxiety-laden issues and antitherapeutic group norms. Anxiety-Laden Issues Often an issue arises in the group that is so threatening that the members refuse to confront the problem and take some evasive action. This evasion can take many forms, all of which are commonly referred to as group flight—a regression from the group’s normal functions. The anxiety may stem from a number of different sources, including anything that poses a threat to group integrity, group safety, and group function. Although the entire group may share in the group tension, the tension may activate different reactions in members based upon their core concerns. Here is a clinical example of flight from an anxiety-laden issue: > Six members were present at the twenty-fifth group meeting I (IY) led; one member, John, was absent. For the first time, and without previous mention, one of the members, Mary, brought her dog to the meeting. The group members, usually animated and active, were unusually subdued and nonproductive. Their speech was barely audible, and throughout the meeting they discussed safe topics on a level of impersonality appropriate to a large social gathering or cocktail party. Much of the content centered on study habits (three of the members were graduate students), examinations, and professors (especially their untrustworthiness and defects). Moreover, the most senior member of the group discussed former members who had long since departed from the group—the “good old days” phenomenon. Mary’s dog, a restless creature who spent most of the group session noisily licking its genitals, was never mentioned.
Finally, thinking I was speaking for all the group members, I brought up the issue of Mary’s having brought her dog to the meeting. Much to my surprise, Mary—a highly unpopular, narcissistic member—was unanimously defended. Everyone denied that the dog was in any way distracting, leaving me, the protesting therapist, dangling in the wind. << I considered the entire meeting as a “flight” meeting, and accordingly made appropriate group-as-a-whole interpretations. But first, what was the evidence that the meeting was in flight? And flight from what? First, consider the age of the group. In a young group, meeting, say, for the third time, such a session may be a manifestation not of resistance but of the group members’ uncertainty about their primary task and of their groping to establish procedural norms. However, this group had already met for many months and had consistently operated at a more mature level. It becomes very evident that the group was in a flight mode when we examine the preceding group meeting. At that meeting, John, the member absent from the meeting under consideration, had been twenty minutes late, and he happened to walk down the corridor at the precise moment when a student opened the door of the adjoining observation room in order to enter it. For the few seconds while the door was open, John heard the voices of the other group members and saw a room full of observers viewing the group; moreover, the observers at that moment happened to be giggling at some private joke. John, like all the group members, had of course been told that the group was being observed by students. Nevertheless, this shocking and irreverent confirmation stunned him. When John, in the last moments of the meeting, was finally able to discuss it with the other members, they were equally stunned. John, as I mentioned, did not show up for the next session. This event was a catastrophe of major proportions for the entire group—as it would be for any group. It raised serious questions in the minds of the members. Was the therapist to be trusted? Was he, like his colleagues in the observation room, inwardly giggling at them? Was anything he said genuine? Was the group, once perceived as a deeply human encounter, in fact a sterile, contrived, laboratory specimen being studied dispassionately by a therapist who probably felt closer allegiance to “them” (the others, the observers) than to the group members? Despite—or, rather, because of—the magnitude of these painful group issues, the group declined to confront the matter. Instead, it engaged in flight behavior, which now became understandable. Exposed to an outside threat, the group members banded tightly together for protection. They spoke softly about safe topics so as to avoid sharing anything with the outside menace (the observers, and, through association, the therapist). I was unsupported by all the group members when I asked about the obviously distracting behavior of Mary’s dog. The “good old days” was a reference to and yearning for those bygone times when the group was pure and open, and I could be trusted. The discussion of examinations and untrustworthy professors was also a thinly veiled expression of members’ attitudes toward me. The precise nature and timing of the intervention is largely a matter of individual style, and the intervention itself can involve varying levels of inference, starting with a direct observation and moving as required to an interpretation of deeper explanatory meaning. Some therapists, as is our preference, tend to intervene when they sense the presence of group flight even if they do not clearly understand its source. We make such comments as, “I feel puzzled or uneasy about the meeting,” or, “I have a sense there’s a ‘hidden agenda’ today. Could we talk about this?” Or perhaps inquire, “Is there something the group is not talking about today?” We may increase the power of an inquiry by citing the evidence for such a conclusion—for example, in this instance, the whispering, the shift toward neutral topics and a noninteractive, impersonal mode of communication, or my experience of being left out or of being deserted by the others regarding the obvious distraction of the dog. Furthermore, we might add that the group is strangely avoiding all discussion both of the previous meeting and of the absent member. In one way or another, however, the problems of the group as a whole must be addressed before any meaningful interpersonal work can resume. In this clinical example, would we be satisfied merely with getting the group back on the track of discussing more meaningful personal material? No! More is needed: the issues being avoided are too crucial to the group’s existence to be left submerged. This consideration was particularly relevant in this group, whose members had insufficiently explored their relationship to me. Therefore, I repeatedly turned the group’s attention back to the main issue—their trust and confidence in me—and tried not to be misled by substitute behavior, such as the group offering another theme for discussion, perhaps even a somewhat charged one. My task was not simply to circumvent the resistance, to redirect the group to work areas, but to plunge the members into the source of the resistance—in other words, not around anxiety, but through it. Another clue to the presence and strength of resistance is the group’s response to therapists’ resistance-piercing commentary. If therapists’ comments, even when repeated, fall on deaf ears, if therapists feel ignored by the group, or if they find it extraordinarily difficult to influence the meeting, then it is clear that the resistance is powerful and that the group needs to be addressed as well as the individual members. Doing so is not an easy undertaking. It is anxiety-provoking to buck the entire group, and therapists may feel deskilled in such meetings. The group may also avoid work by more literal flight—absence or tardiness. Whatever the form, however, the result is the same: Movement toward the attainment of group goals is impeded, and the group is no longer engaged in its primary task. Not uncommonly, the issue precipitating the resistance is discussed symbolically. We have seen groups deal with their uneasiness about observers metaphorically by conducting long discussions about other types of confidentiality violations: for example, computer hacking of private information, family members checking smartphones, and invasive credit card company procedures. Discomfort about the therapist’s absence may prompt discussions of parental inaccessibility or death or illness. Generally, the therapist may learn something of what is being resisted by pondering a key question: “Why is this particular topic being discussed, and why now?” An experience in a therapy group at the height of a very disruptive and challenging influenza epidemic is illustrative: > A group in a partial hospitalization program for depressed seniors was canceled for several weeks and finally reconvened, but with the proviso that all participants were required to wear uncomfortable and oppressive face masks (heeding the recommendation of infection control) that obscured nonverbal communication. The meeting was characterized by unusually hostile comments about deprivations: uncaring adult children, incompetent public health officials, and unavailable, neglectful therapists. Soon the members began to attack one another, and the group seemed on the brink of total disintegration.
I (ML) was also struggling with the restrictive mask and asked for a “process check”—that is, I asked the group to stop for a moment and reflect on what had been happening so far in the meeting. The members all agreed that they hated what the flu crisis had done to their group. The masks not only were physically irritating, but they also blocked them from feeling close to others in the group. They realized, too, that the generalized anger in the group was misplaced, but they did not know what to do with their strong feelings.
I made a group-as-a-whole interpretation: “There’s a sort of paradox here today. It’s evident that you cherish this group and are angry at being deprived of it, yet, on the other hand, the anger you experience and express threatens the warm supportive group atmosphere you so value.” A lot of head nodding followed my interpretation, and the anger and divisiveness soon dissipated. << Antitherapeutic Group Norms Another type of group obstacle warranting a group-as-a-whole interpretation occurs when antitherapeutic group norms are elaborated by the group. For example, a group may establish a “take turns” format in which an entire meeting is devoted, sequentially, to each member of the group. “Taking turns” is a comfortable or convenient procedure, but it is an undesirable norm, because it discourages free interaction in the here-and-now. Furthermore, members are often forced into premature self-disclosure and, as their turn approaches, may experience extreme anxiety or even decide to terminate therapy. It is a content solution for a process problem that must be addressed directly at the process level. Alternatively, a group may establish a pattern of devoting the entire session to the first issue raised in that session, with strong invisible sanctions against changing the subject. Or there may be a “Can you top this?” format, in which the members engage in a spiraling orgy of self-disclosure. Or the group may develop a tightly knit, closed pattern that excludes outlying members and does not welcome new ones. To intervene effectively in such instances, therapists may need to make a group-as-a-whole commentary that clearly describes the process and the deleterious effects of the taking-turns format (or other patterns) on the members or on the group, emphasizing that there are alternatives to this mode of opening each meeting. Frequently, a group, during its development, bypasses certain important phases, or never incorporates certain norms into its culture. For example, a group may develop without ever going through a period of challenging or confronting the therapist. Or a group may develop without a whisper of intermember dissension, without status bids or struggles for control. Or a group may meet at length with no hint of real intimacy or closeness arising among the members. Such avoidance is a collaborative result of the group members implicitly constructing norms dictating this avoidance. Therapists who sense that the group is providing a one-sided or incomplete experience for the members often facilitate the progress of the group work by commenting on the missing aspect of the group’s life. (Such an intervention assumes, of course, that there are regularly recurring, predictable phases of small group development with which the therapist is familiar—a topic we will discuss in Chapter 10.) The Timing of Group Interventions For pedagogical reasons, we have discussed interpersonal phenomena and group-as-a-whole phenomena as though they were quite distinct. In practice, of course, the two often overlap, and the therapist is faced with the question of when to emphasize the interpersonal aspects of the transaction and when to emphasize the group-as-a-whole aspects. This matter of clinical judgment cannot be neatly prescribed. As in any therapeutic endeavor, judgment develops from experience (particularly supervised experience) and from intuition. As Leonard Horwitz suggested, the group therapist must listen with a “fourth ear” to supplement the traditional “third ear” of the individual therapist. The fourth ear allows us to draw from the interplay of individual, interpersonal, and group-as-a-whole experiences.70 As a general rule, an issue critical to the existence or functioning of the entire group always takes precedence over narrower interpersonal issues. As an illustration, let us return to the group that engaged in whispering, discussion of neutral topics, and other forms of group flight during the meeting after a member had inadvertently discovered the indiscreet group observers. In that meeting, Mary, who had been absent at the previous meeting, brought her dog. Under normal circumstances, this act would clearly have become an important group issue: Mary had consulted neither with the therapist nor with other members about bringing her dog to the group; she was, because of her narcissism, an unpopular member, and her act was representative of her insensitivity to others. However, in this meeting there was a far more urgent issue—one threatening the entire group—and the dog was discussed not from the perspective of facilitating Mary’s interpersonal learning but as a way to enable the group to persist in its flight. Only later, after the obstacle to the group’s progress had been worked through and removed, did the members return to a meaningful consideration of their annoyance about Mary bringing the dog. To summarize, group-as-a-whole forces are continuously at play in the therapy group. The therapist needs to be aware of them in order to harness group forces in the service of therapy and to counter them when they obstruct therapy. We treat individuals and not the group entity, but at pivotal points our attention must turn to the group as a whole in order to treat the members of the group. Footnotes i Metacommunication refers to communication about a communication. Compare, for example: “Close the window!” “Wouldn’t you like to close the window? You must be cold.” “I’m cold, would you please close the window?” “Why is this window open?” Each of these statements contains a great deal more than a simple request or command. Each conveys a metacommunication: that is, a message about the nature of the relationship between the two interacting individuals. ii Such phenomena play havoc with outcome research strategies that focus on initial target symptoms or goals and then simply evaluate the clients’ change on these measures. Using more comprehensive global outcome questionnaires instead, such as the Outcome Questionnaire 45, or Partners for Change Outcome Management System (PCOMS), can provide meaningful feedback to therapists that keeps them aligned productively with their clients. See G. Burlingame, K. Whitcomb, S. Woodland, J. Olsen, M. Beecher, and R. Gleave, “The Effects of Relationship and Progress Feedback in Group Psychotherapy Using the Group Questionnaire and Outcome Questionnaire-45: A Randomized Clinical Trial,” Psychotherapy 55 (2018): 116–31. B. Wampold, “Routine Outcome Monitoring: Coming of Age—With the Usual Developmental Challenges,” Psychotherapy 52 (2015): 458–62. iii Bion’s rich understanding of groups emphasized that group life occurred at two levels: the work group, which was conscious, rational, and focused on its tasks; and the basic assumption group, which was unconscious, irrational, and resistant to and avoidant of its task or duties. The basic assumption group is a regressive response to group anxiety and takes three forms: Dependency Assumption—in which the group members feel helpless and desperate for rescue by the leader, who may also be attacked for being unresponsive; Fight-Flight Assumption—in which the group is paranoid and mistrustful, looking to attack or preparing to be attacked; and Pairing Assumption—in which the group fantasizes about rescue by virtue of a new mating relationship being formed. See R. Billow, “On Resistance,” International Journal of Group Psychotherapy 60 (2010): 313–46. W. Bion, Experiences in Groups and Other Papers (New York: Basic Books, 1959). For more information about Bion’s contributions, see an earlier edition of this text. References Brown, N. W. (2018-01-29). Psychoeducational Groups, 4th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781351689410 Yalom, I. D., Leszcz, M. (2020-12-01). The Theory and Practice of Group Psychotherapy, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9781541617568 image7 image8 image9 image10 image11 image12 image13 image14 image15 image1 image2 image3 image4 image5 image6
